NCC241635_FRO Submitted_20240611

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 Camp Sutton Mixed Use
2. Address where land disturbing activity will take place 372 Acme Drive
3. Approximate date disturbing activity will commence 08 / 14 / 2022
4. Purpose of development(residential,commercial,industrial,etc.) Mix-use
5. Total acreage of land to be disturbed or uncovered 24.32
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.) $2,900
Was previously 23.91 ac now 24.15=$500+24 @$100
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Tom Crouch Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
Name UC QOZB I, LLC Name
Mailing Address 231 Post Office Drive,Suite B8 Mailing Address
Indian Trail,NC 28079
Street Address Street Address
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 8147 8147 Book 8104
Page 0151 166 Page 0696
10. Tax Map Parcel Number where land disturbing activity will take place 09 122 001
09 __ 117__ 008
09 __ 122 __ 002
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 UC QOZB I, LLC Name
Mailing Address 231 Post Office Dr.,Ste B8 Mailing Address
Indian Trail, NC 28079
231 Post Office Dr.,Ste B8
Street Address Street Address
Indian Trail, NC 28079
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 Dennis Moser
Mailing Address 231 Post Office Dr Suite B8 Indian Trail, NC 28079
Street address City State Zip
`704-882-1700 O
Phone Email M3 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 Nameb ►115 Mk. 5-1 Title -VVktjel(
Signature Date g ; ( �
Rwte. 1�--H• 1 7 T �� a Notary Public of the County of�. Zt/t ()North()North.State()North Carolina.
hereby certify that _e yu_S appeared personally before me his day and being duly sworn acknowledged
that the above Iomt was executed by him. `(j +
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Witness tnv hand and notarial seal.this I I "". day of Lai— . ?A
. RAENAE H. LITTLE
NOTARY PUBLIC (Notary)
County North ,r" /4 - V�
North Carolina My commission expires L�-
Zo
My Commission Expires April 16.2022
07-19 Permits. Checklists. and Forms
Division 07