NCC221815_FRO Submitted_20220511

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Bryce A_ Stuart Municipal Building
Suite 328
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Winston-Salem, NC 27101
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DIVISION
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Erosion Control Permit Application Operations
P.O. Box 2511
Winston-Salem, NC 27102-2611
Please use this form when the Developer and Builder are not the same
Phone: 311 or [phone]
Fax: [phone]
financially responsible party/person and will be less than one (1) acre of
land disturbance on any one (1) lot.
Lot(s) to be Developed Information
Site Address: r' !i Am F
7 4F
Subdivision Name:
Anticipated Dates of Construction Activity: Start:. �� Z— Z Z Completion;
*** Complete the LOT INFORMATION TABLE for each lot to be developed; ensure that the appropriate drainage pattern type is
denoted. Attach a corresponding, existing platted survey for each lot with your application, please. If not, your permit
application may not be accepted for review. ***
Financially Rjwl!5�hsible Party/Person
Address: 17 0 1,6
City/State/Zip: W� �7 / C- Office Phone: ?f �li — 22 tl —54 Z�
#Mobile Phone: !94-16 l r ,�� Email Address, w j u iS�t� e d+✓�
My signature hereto signifies I am the owner/financially responsible party forjob site compliance with the Erosion Control Ordinance
as outlined in Chapter, Section 8.4 of the Unified Development Ordinances (UDO) of the City of Winston-SalemlForsyth County or
Article IV of the UDO of the Village of Clemmons, Town of Lewisville, or Town of Walkertown. I hereby acknowledge that the Best
Management Practices annotated on the attached sketch plan must be properly installed and maintained to retain soil within the
constructed lot.
I understand that if the total disturbed area for any reason becomes greater than one acre on any one (1) lot, a professionally designed
and sealed Erosion Control Plan will be required to be submitted and approved before the start of the land disturbing activity on the lot- I
further acknowledge that City Inspection's staff may refuse to make building inspections and the Erosion Control Division may issue
Notices of Violation, Stop Work Orders and/or Civil Penalty Assessments for failure to comply with Erosion Control requirements.
Print Name of Financially Responsible Person uFe of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: