NCC216275_FRO Submitted_20211110

CITY OF MONROE Sr XNDARD SPECIFICATIONS AND DETAIL MANUAL
07.06 EROSION CONTROL FORMS AN D CHECKLISTS
07,06.01 FROSION CON"I'ROL I-INANC1A1.1ESSPONSIB11.11'Y FORM
No person may initiate any land-dtsrurbing, actn, rty as defined in Chapter 158 ol-the Monroe 0q Code pnor to
completion of this form, and an applicable and acceptable erosion and sedimentation control plan has meet) appro-ved by
the City of Monroe Engineering Departmew. (Please type or print)
Pat -I. I
Bona
I Name
2 Address Where land disturbing acto,W, call tame place- _ 4-110Propel Way, Monroe, N.C.
Parcel: 09399002E
3 approximate date d:sturbinc activity i%id commence 10r 28 2021
4. Purpose of tlevv'opment tro idential, conirnerciaL industrial, etc.) Industrial - ----- --
5 'rotat acraagc of lzmd to be disturbed or uncovori.d 28.81
b Amotint of fee enclosed (fee will he the amount of current policies per acre mjlttphed by the total number
at acres or any par€ or an acre froin nuiriber -r, i e 7 8 acres equals 8 acres.)- _ - $2,800.00
Agurt to Lontact should sediment c(.�ntrol Issues arise during land disturbing ai tiv;iv
Name Kevin Caldwell Phone [phone]
S I andowncr{-�t ofRccord (use blank- page to list additional owners)
Name Bonakemi USA, Inc.
Mailing Address 24 Inverness Place, Suite 104Hailing
Englewood, CO 80112
Street Address ...__ _ -._ Street Address _—
Phone.--. _- -- - ------ --- -- Phone
Fax-- _�._.__ __.-_- ---- I•�tx----- - - .... - _ _.-_.�.� _._..._
9. Indicate, Bank and Page where deed of the property where land disturbing activvt - Lk III ',;Lke place is recorded
(use h1:ink page to list additional ov+nc-rs)
Bilol, 8165 Book
pa^c 020E -. Pa0e - - -- — - - -
I ti. -I a% %lap Parcel Numher where land di,iurbing activity a ill take place 093 -- _ 99__ 002E
07-1 S Permits, Checklists, and Forms
Division 07

CITY OF MONRO1F, SIANt ARD SPRIFICA7IONS AND DETAIL MANUAL
Part 11
I. Person(s) or Firms) ,whe are financially responsible for this taus# disturbing activity (use blank page to list
addition l.o '1 ',LLC - Galen Heyin
Name g Name
Mailing :'Address------ _ — —._. _ Mailini .Address
2359 Perimeter Pointe Parkway, Suite 600, Charlotte, N.C. 28208
Street Address same Street Address
Phs3nc Phone
Fay Fax
Z A) If the i inanctally Rc4pon%ible l'any r, not a resident of North Carolina, give mole and address of a Nurth
Carolina Agent
Name of Registered Agent —
N1aihrigAdJl-e,3----
`strecl addre%-, City State Zip
Phone #:trail # ax
B) If the Financial#y Responsible Parts is a Partnership or other person enganing in business under an assumed
name, attach a copy of the Certificate of Assumed 'Same. If the Financial!% Responsible fart^% is a
C'orpotation. give t#is name and street address of the Registered Agent;
Mine of Registered Agent___. ._. .
Mailing Addtcys J
Street address City State Zip
Pllone T-mail Fax
I he above information is true and correct I., the !zest of illy knowledge and belief and 4Nas provided b� tilt:
under oath I agree to provide corrected intormation should there be -m3 change.: in dw information provided
herein (This Form roust be signed by the financially responsibh: person if an tndivicltial or It;< i(nrne3 in fact,
or if not an individual, by an ofticrr, director. partner, or registered agent with atuhoriiN to vs3_L:silt insirurnetit'-
for the financially respow ible person)
Type nr Print len Heying 'f itle Project' -Manager - -
Signature t Date 10 21 2021
f AcT _.,!u> t4i� _. voutry Public ofthe Cutitzl} of Male oCNorth t me=i,e4,-
hertbv kartlii tills �_+.L o%LLe a f4e-v f.V6, .. appeAi d pf:minalTv before toc this day and hvingG idly swum acl.f1E15 0gi d
that ;l<ij`IC rig ' ikl4'[t ['\ tills'!.
hand.tral nnr,t ll s1. tin, Z I dtti ofle
N U r A R
U8 L I G 2� r>tRtan� j
'RG GO B` 07-19 Pennith. C hccklists, and I-onns
11 Di, iston 07