NCC233099_FRO Submitted_20231016

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
I. Name of Project r•L
2, Address where land disturbing activity will take place 0 900 01 el e-dhG rib li wy
il ovl,rr)e cq( ))D
3. Approximate date disturbing activity will commence / o / /6 / .PDQ3
4. Purpose of development(residential,commercial, industrial,etc..))l ILLIci64l6.,
5. Total acreage of land to be disturbed or uncovered b . k 1
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.)4 al b°�air�of on fsl z
1 100 a4 )
7. Agent to contact should sediment control issues arise during land disturbing activity 3 fk� 7�*pr3
Name 74 m S Lcg 8 Phone 7o ( t:)/ L13 9'1
8. Landowner(s)of Record(use blank page to list additional owners)
Name Monroe 4 i L Le_ Name
Mailing Address 500 leAri ekeln /145 Mailing Address
M 44}se+vij AJ L 9 4)06
Street Address ,.,S1 W I►r+WtA Street Address
. 1w OS de:. 4'ft)OS-
Phone "RA 5 b--- , 3 Phone
Fax /lJ✓✓/4- Fax
9. Indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank rpage to list additional owners) —y
Book 7, k-? Book I CO 9
Page O I bfl/6-- Page (92.0 " 0gd.c'`S
10. Tax Map Parcel Number where land disturbing activity will take place 043 --g®1 / 629
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 financially responsible for this land disturbing activity(use blank page to list
additional owpers) rr ii
Name Erd.S+�aod t:o1)g rvc�vh P ( tsi 1L-Name
Mailing Address eA57 100 50(41211 Mailing Address
6114/14 kjt✓ a Sa01
Street Address a S 7 &%or" r2 Street Address
0440 ,.NC. glsabk
Phone 7oN- 5'07 3 Phone
Fax A)//4- 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
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, 1 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) ` j �
Type or Print Name 11 r? 1-fufr\irts Title Chas! f-trranLp4,l eggi.hc
Signature Date 9 �3
{ _ • -N1,4 a iNotary Public of the County of 1 rtiGG l ,State of North Carolina,
hereby certify hat V i 5 appeared personally before me this clay and being fitly sworn acknowledged
that the above form was executed by him.• �M
,yp„nr,rrrrr 4:4 f '"
Witness,r l d d i 'rrtt,,al,this "day of a�✓sr: ./ � . .
" (Not
� , My commission expires
-!/ 2�
• UB L'G / d 07-19 Permits, Checklists, and Forms
rss��.' �` °C .
ss Q ., -- �,�-k .♦ DIvision 07
Leo
COO 'a
,POeej�ildll A;l44;y54d04