HomeMy WebLinkAboutNCC232714_FRO Submitted_20230929 CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL 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 prior to
completion of this form,and an applicable and acceptable erosion and sedimentation control plan has been approved by
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Project +/- 42,000-SF Warehouse Expansion for CCBCC - Monroe
2. Address where land disturbing activity will take place 4268 Capital Dr. Monroe, NC 28110
3. Approximate date disturbing activity will commence 09 / 01 / 2023
4. Purpose of development(residential,commercial,industrial,etc.) Commercial
5. Total acreage of land to be disturbed or uncovered 1.88
6. Amount of fee enclosed(fee will be the amount of current policies per acre multiplied by the total number
of acres or any part of an acre from number 5. i.e.7.28 acres equals 8 acres.) $700
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Ethan Hart Phone (803) 331-2991
8. Landowner(s)of Record(use blank page to list additional owners)
Name CCBCC Operations, LLC Name
Mailing Address 4100 Coca-Cola Plaza Mailing Address
Charlotte, NC 28211
Street Address 4100 Coca-Cola Plaza Street Address
Charlotte, NC 28211
Phone (704)488-0429 Phone
Fax Fax
9. 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 3658 Book
Page 288 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 -- 399 __ 009
07-18 Permits, Checklists, and Forms
Division 07
CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
1. Person(s)or firm(s)who are fmancially responsible for this land disturbing activity(use blank page to list
additional owners)
Name Fitts and Goodwin, Inc. Name
Mailing Address 120 Corporate Blvd. Mailing Address
West Columbia, SC 29169
Street Address 160 Mine Lake Ct. Ste 200 Street Address
Raleigh, NC 27615-6417
Phone (803)796-4660 Phone
Fax Fax
2. 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
Mailing Address NC 27615-6417
Street address City State Zip
Phone Email Fax
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 Address
Street address City State Zip
Phone Email Fax
3. 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 Print Nme Thomas Fitts Title President
vSignature J( � Date 08 / 22 / 2023
South
I, Susan I ourigan ,a Notary Public of the County of Richland ,State of-P1e##Carolina,
hereby certify thatThomas M. Fitts, Jr. - President appeared personally before me this day and being tidy sworn acknowledged
that the above fonn was executed by him.
Witness my hand and notarial seal,this 22nd day ofAugust, 2023
SEAL O LOUR/ 'y, C/I A
( otary);SU1oc&.n
rli‘-)
I My commission expires 04/14/2033
�=N'•AveIA�/T.§ 07-19 Permits, Checklists, and Forms
��' �'�'_,,,,,, �� Division 07