NCC230899_FRO Submitted_20230331

CITY OF MONROE
STANDARD SPECIFICATIONS AND DETAILI MANUAL
07.06 EROSION CONTROL FORMS AND CHECKLISTS
07.06.01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land -disturbing activity as defined in Chapter 158 of the Monroe City Code
completion of this form, and an applicable and acceptable erosion and sedimentation control plan has bi
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Proiect Wil
2
3
4
5
prior to
yen approved by
Address where land disturbing activity will take place 1 bbz t. KOOseyelt biva trols,l
Monroe, NC 28112
Approximate date disturbing activity will commence 04 / 01 2023
Purpose of development (residential, commercial, industrial, etc.) Residential
Total acreage of land to be disturbed or uncovered 25.3
6. Amount of fee enclosed (fee will be the amount of current policies per acre multiplied by the
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.)$3,000 (1 AC.
7
8
Q
no
Agent to contact should sediment control issues arise during land disturbing activity
Name Jeremy Horton Phone [phone]
Landowner(s) of Record (use blank page to list additional owners)
Name E & O LesMarChris Family Limited Partnership
Mailing Address 7109 Anchorage Lane
Tega Cay, South Carolina 29708
Street Address7109 Anchorage Lane
Tega Cay, South Carolina 29708
Mailing Address LL4 VI
Monroe, NC 28112
number
25 AC. @ 100)
Free Church of Monroe, North Carolina
0
Street Address 224 Old Highway 74
Monroe, NC 28112
Phone Phone
Fax Fax
indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank page to list additional owners)
Book 5459 Book 480
Page 795 page 141
Tax Map Parcel Number where land disturbing activity will take place 09 -- 121 -- 002A
09 121 004
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
I. Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name M/1 Hnmps of CharintFP I I C , Name
Mailing Address 4131 Worth Avenue, Suite 500
Columbus, OH 43219
Mailing Address,
Street Address 4131 Worth Avenue, Suite 500 Street
Columbus, OH 43219
614-418-8000
A) If the Financially Responsible Party is not a resident of North Carolina, give name and address of a North
Carolina Agent
Name of Registered Agent Coporation Service Company
Mailing Address 2626 Glennwood Ave Ste 550 Raleigh NC 27608
Street address City State Zip
Phone Emai
B) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a
Corporation, give the name and street address of the Registered Agent:
Name of Registered Agent
Mailing
Street address City State Zip
Phone Emai
F
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath. I agree to provide corrected information should there be any change in the information provided
herein. (This form must be signed by the financially responsible person if an individual or his attorney in fact.
or if not an individual, by an officer, director, partner, or registered agent with authority to execute instruments
for the financially responsible person)
Type or Printer lffh Jeremy HdrtM Title Director of Land Entitlements
Signatu
Date Z / Z2 / 102-3
llp/be.cua a Notary Public of the County of Me GK 1eh f(.I State of North Carolina.
hereby certify thatT6l'� ((Mdsworn acknowledged
'YI appeared personally before me this day and being cLly swoacknowledged
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`tl��ihitc o�e `fho va s executed by him.
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ZZI M-•7 d)ndarial seal, this day of
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Xe�ckzlists. and Forms
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Division 07