NCC222952_FRO Submitted_20220818

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INOMSIONS
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Single -Family Dwelling
Erosion Control P e r m i t Application
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City of Winston-Salem
Field
Operations
Please use this form when the Developer and Builder are not the same
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: 0 -T1�j, \J i Ili
Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
P.O. Box 2511
Winston-Salem, NC 27102-2511
Phone: 311 or [phone]
Fax: [phone]
Subdivision Name: T
Anticipated Dates of Construction Activity: Start: t SI 2 027- Completion: 1 O i i 71
*** 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. I
Financially Responsible Party/Person
Name: f , �,60n (\C -• I —,,a AS
Address: `f 15 O M e_VlA on k&J � Q 0LY 5 ?&,(V_y10.� v . �ts 1 + (; IL) f -
City/State/Zip: l�4, �'>n 'a n-k I4 t- Z-1 2 Office Phone:
Mobile Phone: i-I--{�'t -21 �3 Email Address:-+m6QLVi5 I r-�n CJD'"''`
My signature hereto signifies I am the owner/financially responsible party for job 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-Salem/Forsyth 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 comply with Erosion Control requirements.
1 1 UA
Print Name of Financi Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
Signature of Financially Responsible Person