NCC233615_FRO Submitted_20231207

roiFne Bryce A.Stuart Municipal Building
Suite 328
1 100 E.First Street
a Single-Family Dwelling u��r� rm
city cif Winston-seer., Winston-Salem:NC 2710'1
INSPECTIONS
DIVISION Field P.O. Box 2511
r!c''""'" Sen'fac
Erosion Control Permit Application Operations Winston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone:311 or 747 7453
p Fax:{336)727-2792792
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: 8936 /77,,e TCs E= C'r G Fw>s v/ L C 2 `742 3
Subdivision Name: / 42
Anticipated Dates of Construction Activity: Start: /'- e-e 3 Completion: -$- 2 `ee
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: "Wygd'e y . ive--
Address:
City/State/Zip: srP/15 V7 . / L� e7.2 3 V Office Phone:
Mobile Phone:334-7V,,-- G3'Z. Email Address: na fi7/4Xfe y bor;/der -,C c
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 comply with Erosion Control requirements.
,r//i'I /r)y91fCN u`
Print Name of Financially Responsible Person ignature of Financially onsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: