NCC220937_FRO Submitted_20220303

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
L Name of Project Union Academy Ballfields
2. Address where land disturbing activity will take place 400 N. M. L. King Jr. Blvd.
3. Approximate date disturbing activity will commence 1 / 1 / 2022
4. Purpose of development (residential, commercial, industrial, etc.) Commerical
5. Total acreage of land to be disturbed or uncovered 8.51
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.) $ 1 , 300
7. Agent to contact should sediment control issues arise during land disturbing activity
Name John Wiggins Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name Union Academy Name
Mailing Address 675 N. M LK Jr. Blvd. Mailing Address
Monroe, NC 28110
Street Address 675 N. MLK Jr. Blvd. Street Address
Monroe, NC 28110
Phone [phone] Phone
Fax NSA 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 6846 Book
Page 746 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 __ 31 __ 6005B
07-1 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part 11
Person(s) or hrm(s) who are linanciall% responsible for this land disturbing activih (use blank page to list
additional ok\ners)
Name Union Academy Name
F'i^75 Ni nn i. RIVd. Mailing Ad
Vailinu address °r �T�
Monroe, NC 28110
St,.ect, ddres,-675 N. MLK Jr. Blvd.
Monroe, NC 28110
Phone [phone]
Fax N/A
Street ;Address
Phone
Fa,�
A) If the Financially Responsible Party is not a resident ot'North Carolina. give name and address of a North
Carolina Anent
13) 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 Part; is a
Corporation. give the name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone#
Email Address
Current Street Address
City State
Fat#
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 Name Aj
Signature !• `v`i'' L
Title, / ,
Date Ic I 1,124, I 21
I M A/Z LIAA' �(11 RD l./'Va, Notary Public of the County of S 1 %�L State of North Carolina.
hereby certify that Z-V Nt/ W / Cj C, /NS _ appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him.
Witness my hand and notarial seal. this _ "'day of U G T 0 1,3 ` C)— (0 d-- _
SEAL MARYANN BROWN 1410��
NOTARY PUBLIC (Notary)
Stanly County
North Carolina My commission expires
My Commission Expires Oct. 14, 2026 --
07-2 Permits. Checklists. and Forms
Division 07