NCC233675_FRO Submitted_20231218

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 Blair Place
2. Address where land disturbing activity will take place 2514 Fowler-Secrest Road Erois
3. Approximate date disturbing activity will commence 01 / 01 / 2024
4. Purpose of development(residential,commercial,industrial,etc.) Residential
5. Total acreage of land to be disturbed or uncovered 35.33 acres
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.) $4,000
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Gil Squires Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
Name Mattamy Carolina Corporation Name
2127 Ayrsely Town Blvd, Suite 202
Mailing Address Mailing Address
Charlotte,NC 28273
Street Address 2127 Ayrsley Town Blvd,Suite 202 Street Address
Charlotte,NC 28273
Phone [phone] 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 08818 Book 08818
Page 0893-0896 Page 0897-0899
10. Tax Map Parcel Number where land disturbing activity will take place 09 __298 __ 080
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
Person(s)or firm(s)who are financially responsible for this land disturbing activity(use blank page to list
additional owners)
Name Mattamy Carolina Corportaion Name
2127 Ayrsley Town Blvd,Suite 202
Mailing Address Mailing Address
Charlotte,NC 2827a_____ — T
Street Address 2127 Ayrsley Town Blvd,Suite 202 Street Address
Charlotte, NC 28273
Phone [phone] 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.
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 he 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 Name Johnson Title VP of Land Development`/
Signature/f �' Date / /lam l Z - ._._
i, kat/l t'!7- Ut/(1,1/off _ ,a Notary Public of the County of o f/er ( ,State of North Carolina,
e�hereby certify thatY &jn ciir h1 61n_ appeared personally before me this day and being(illy sworn acknowledged
that the above form was executed by him. �q� p ��ff �j
Witness my hand and notarial seal.this )\.) day of 0ov�Ir16G _. __.11_a 2"
KAYLE A. SCHMIDT
Notary Public, North Carolina jLI '�/ 7,00
Union County My commission expires 2�,__.. /J
My Commission Expires
February15,202$
07-19 Permits, Checklists, and Forms
Division 07