NCC231505_FRO Submitted_20230519

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;o+' (1 Bryce A.Stuart Municipal Building
y Suite 328
Single-Family Dwelling 100 E.First Street
INSPECT DNS
CityoflWins oin-Salem Winston-Salem,NC 27101
DIVISION
Excellence through Service Erosion Control Perm Field P.O. Box2511
i t Application Operations AIPston•Salem, NC 27102.2511
Please use this form when the Developer and Builder are not the same Phone:311 or(336)747-7453
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: Cl223 Tu 1 l ; rv\.e,-e__,r. L.o,--_tom .w:3 v� I (C. t ) C- --)--7 U �
Subdivision Name: .--t L.,:, `._,c-,`t .. 6-^'. -' c/---cam
Anticipated Dates of Construction Activity: Start: 'j/2_ /7 -S Completion: if Z.; / Z
***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 Responsible Party/Person
Name: c — 1". l:ic--c�a.w C cc" 6-� \- ;,-----e--
Address: ? ,, ) , , 'j 1 '7
City/State/Zip: L.-,'s v.l( e_ LL7 L L, zv .5 Office Phone: 3 C., 'r``t --0ft) s
Mobile Phone: 5 3 Q, ._;c-k.5.Z`,..5"Email Address: c :c c _ ' NA,Qr .,,z , -
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 to compl with Erosion Control requirements.
Print Name of Financially Responsible Person 'Signature of Fine y Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: