NCC223227_FRO Submitted_20220921

��twren�yyl
o� 40
INSPEZ 0 S
®IVI I N
&wfleneo thrmjh Service
Single -Family Dwelling
Erosion Control P e r m i t Application
,t1,
wasnum
City of Winston-Salem
Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
Field P.Q Box 2511
Operations Winston-Salem, NC 27102-2511
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:
*r
Phone: 311 or [phone]
Fax: [phone]
rr I 1—� V
Subdivision Name: I b'� � t Ssc-ra—
Anticipated Dates of Construction Activity: Start: 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 ReAponsible Party/Person
Name:
Address: �� S c'� �,pl� r cj R .
City/State/Zip: 2--e-LJ 13V i l`e, �3 C- 22v,13 Office Phone: —q36 Q 2�
Mobile Phone: 336-q I L --90 %O Email Address: l6j 1 h Q- c� o) . Qv Vh
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 LIDO 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
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
Signature of Financially Responsible Person