NCC240825_FRO Submitted_20240322

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 /J�
1. Name of Project /TS6-0✓I I G(� (L l -i )
2. Address where land disturbing activity will take place e9(190' 0I 1UL? &enc:h
Moilro?i NL of (i)O
3. Approximate date disturbing activity will commence 3 / /
4. Purpose of development(residential,commercial, industrial,etc.) et,SIelt ertlw' t!S‘ny[a -Y�^tid1)
5. Total acreage of land to be disturbed or uncovered i I•a U
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.) 0300. v a
7. Agent to contact should sediment control issues arise during land disturbing activity
Name J ecMSS Phone 7O 001 " 39 /
8. Landowner(s)of Record(use blank page to list additional owners)
Name Ol ivc' rtcnc,ii �a tL.LC. Name
Mailing Address /k 00 bi.gowwl c,-It 600 Mailing Address
A-10(u"lleiGti V4 0, 31-1
Streete Address�'OQ IJJ jovi,..l /�c� 5' b OO Street Address
/1"lGL andr),,t ,v4- J07Q3 7
Phone (CID- �`i�- day Phone
Fax /U/4 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 , Book
Page , Qy 1 I Page
10. Tax Map Parcel Number where land disturbing activity will take place 0 9 -- 1`13 -- G 1 y
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 owners)Name e44+ �O (ovi4,fudwi ParkK 1I.LL Name
Mailing Address 0857 GVe.i4 i0o,'T RA, Mailing Address
Ghurlo . NG .Qkaor
Street Address .7&6-7 124 Street Address
Phone 70�A1-' 50-7- 7o 33 Phone
Fax /vl�^ 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) tithe 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. t 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),� —II- ,,�/�
Type or Print Name k�V►✓1 ►'f/J"U'` ifl_c Title Ch bF `i'1nariak P r
Signatur Date / 0l /
I, y1---•00-AlliNotary Public of the County of n eDl n .State of North Carolina.
hereby certify that �Ark 4 j11tSappeared personally before me this day and being dily sworn acknowledged
that the above form was executed by him.
°°°°,611rIpNf
Witness my hand`4n�,taal,aJ. � •-^ day of
- oTA
SEAL � p ,
m (Nora
e -/ �1
- � ; e My commissi expires
<y` aVBO° °4 07-19 Permits,Checklists, and Forms
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Division 07
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