NCC223309_FRO Submitted_20220921

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 Calico Ridge
2. Address where land disturbing activity will take place 4698 Poplin Road, Monroe, NC 28079
3. Approximate date disturbing activity will commence 6 1 I 2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential- Single family_
5. Total acreage of land to be disturbed or uncovered 36 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.) $4,000
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Kevin Roth phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name EHC Homes LP Name
Mailing Address 8008 Corporate Center prive, Mailing Address
Suite 300
Street Address same as above
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 8262 Book
page 519 Page
10. Tax Map Parcel Number where land disturbing activity will take place 08 -- 267 -- 002F
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 EHC Homes LP Name
8008 Corporate Center Drive,
Mailing Address Suite 300 Mailing
Charlotte, NC 28226
Street Address same as above
Phone [phone]
Street Address
Phone
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
Street address City State Zip
Email Fax
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 Party is a
Corporation, give the name and street address of the Registered Agent:
Name of Registered
Mailing Address
Street address City State Zip
Email Fax
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath. 1 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 Nam M-eea—
Signature I U &
Title Req,'OV1 t� U iv V"yi -CA
Date I /Tq-
tyt ► i a Notary Public of the County of ,( j onr-- State of North Carolina,
hereby certify that �'-M; appeared personally before the this day and being dtly swom acknowledged
that the above form was executed by him.
Witness my hand and notarial seal, Atis
SEAL,
NOTARY = tNot
PUBLIC
My commission expires `aoa5
V ai
a7tFPermits, Necklists. and Forms
i,',�11✓CO��' ��,��� Division 07