NCC223435_FRO Submitted_20221012

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INSPENT DNS
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Single -Family Dwelling
_ nBryce A. Stuart Municipal Building
It:IJW Suite 328
100 E. First Street
City of Winst�oo Salem Winston-Salem, NC 27101
Field P.Q Box 2511
Erosion Control P e r m i t Application Operations Winston-Salem, NC 27102-2511
Please use this form when the er and
Builder are not the same Phone: 311 or [phone] financially responsible party/person and will be less than one (1) acre of Fax: [phone]
land disturbance on any one (1) lot.
Lot(s) to be Developed Information
Site Address: H 'Z� C-,' O s s i � � Cr{� �,� 1Je�eL C` -, --7 1
Subdivision Name:
Anticipated Dates of Construction Activity: Start: `t 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. ***
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City/State/Zip:2-4�;�>IS\)J; I, I� Office Phone:
Mobile Phone:_ Email Address:
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 co ply with Erosion Control requirements.
Print Name of Financially Responsible Person Signat a of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: