NCC216862_FRO Submitted_20220105

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 Blue Sky Meadows Subdivision
2. Address where land disturbing activity will take place_ 2219 Concord Avenue
Monroe, NC 28110 . Actual Parcel 09-216-042 (DB 4772 - PG 073)
3. Approximate date disturbing activity will commence 12 1 01 / 2022
4, Purpose of development (residential, commercial, industrial, etc.)_ Residential Single Family
5. Total acreage of land to be disturbed or uncovered 65 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.) $6,900
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Tim Derylak Phone 704_216-1666
8. Landowner(s) of Record (use blank page to list additional owners)
Name Franklin W. Howey, Jr. Name Carl Andrew Boggs, III
David Christopher Boggs
Mailing AddressPO Box 1609 Mailing AddressPO Box 1609
Monroe, NC 28111-1609 Monroe, NC 28111-1609
Street Address N/A Street Address N/A
Phone [phone] Phone [phone]
Fax N/A lax N/A
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 4772 Book
Page 73 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 __ 216 -- 042
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 Century Communities Southeast LLC Name
Mailing Address 7401 Carmel Executive Park Dr Mailing Address
Suite 310, Charlotte, NC 28226
Street Address7401 Carmel Executive Park Dr
Suite 310, Charlotte, NC 28226
Phone [phone]
Fax
Street Address
Ph
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
Phone
Email
City State
Zip
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 Agen
Mailing Address
Street address City State
Phone Email Fax
Zip
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 Nar
Signature
►:TifiW-712:+
Title VP of Land Acquisitions
Date 6l 1 Lf 1 2 C% Z
I, Tnw1�1 k1 a Notary Public of the County of _ �Yl _ , 1— State of North Carolina,
hereby certify that rr appeared personally before me this day and being drly sworn acknowledged
that the above form was executed by him.
Wj ffi! 44.nd notarial seal, this day of�.l
� (Notary) - -
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YMy commission expires pnL4W-%r�
07-19 Permits, Checklists, and Forms
+�' pan`•' fly`' Division 07