NCC222029_FRO Submitted_20220601

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 Waxha%, Landing
2. Address where land disturbing activity will take place 2659 Waxhaw. Hw
3. Approximate date disturbing activity will commence 11 J 1 / .2021
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage of land to be disturbed or uncovered 140 acres
6. Amount of fee enclosed (fee will be the amount of current policies per acre multiplied by the total number
,pall in March 2021
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $14,400..00
7. Agent to contact should sediment control issues arise during land disturbingactivity
Name Phone_n
8. Landowner(s) of Record (use blank page to list additional owners)
Name Mattamy Carolina Corporation Name
Mailing Address127 Ayrsley Toym Blvd, Suite 202 Mailing Address
Charlotte; NC 28273
127 Ayrsley Town Blvd, Suite 202
Street Address Street Address
Charlotte, NC 28273
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 7926 Book
Page 0361 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 __ 351 014
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 fist
additional owners)
Name Mattamy Carolina Corporation Name
Mailing Address 127 Ayrsley Tovrn Blvd, Suite 202 Mailing Address
Charlotte, NC 28273
Street Address 127 Ayrsley Town Blvd, Suite 202 Street Address
Charlotte, NC 28273
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
13) 1 f 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
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. 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 Name0� 1rt64911J Title
Signature Date 2�L/_z%
1• h�t.� a Notary Public of the County of State oi' Soutl' �r rna;
5....._ __ ..., 6
hereby certify that, -Btlzb ql'� appeared personally belie°c me this day and t}cirt dil sw
4 pP p Y } 6 y
that the above l'onn was executed by him.O
Witness my hand and uotarialscal, this day of O
SrAt = °�
(Notary) � (� m�-: (,i$'��G
r
My commission expires
07- 19 "".•••-
Permits, Checif?S s A' a�