NCC233826_FRO Submitted_20240104

p Bryce A,Stuart Municipal Buiiaing
Suite 328
rh `� Single-Family IDWelling 1lWn to 100 E.First Street
I Cidor4Vlnsto-saiem Winston-Salem,NC 27101
INSPECT DNS
DIVISION Field P.O. Box 2511
l'et:"cerrrngA "'" Erosion Control Permit Application Operations ligati Winston-Salem. NC 27102-2511
Please use this form when the Develo per and Builder are not the same Phone=311 or(336)747 7453
p Fax:[phone]
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: '7V7 i772 c /7 S 41./9/ /eLv,5.1/eze e Z772
Subdivision Name: Ziloc,c1''1--ie-c✓ SAS s
Anticipated Dates of Construction Activity: Start: /Z•/e- Z3 Completion: -/8 . Z3
W%* 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 PartylPerson
Name: /7s1Xe-- y .0?.U/e s T,4C
Address: //y .fie/
City/State/Zip: 7,'riv�r3vr/� 277 '/ Office Phone:
Mobile Phone: 336- 7/?- 32z Email Address: M Q inarre•Y ler;ider_s .<a rig
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 he properly installed and maintained to retain soil within this
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.
-7;W Alley
Print Name of Financially Responsible Person ignature of Financial) e. onsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: