NCC230376_FRO Submitted (2)_20230213

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
0
Name of Project Blue Sky Meadows (Phase 4 & 5)
Address where land disturbing activity will take place 2219 Concord Avenue, Monroe, NC 28110
3. Approximate date disturbing activity will commence 01 1 15 y 2023
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage of land to be disturbed or tine :oei ed 44 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.) $4800
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Johnny Evans Phone [phone]
S. Landowner(s) of Record (use blank page to list additional owners)
Name Century Communities Southeast LLC Name
Mailing Address 7401 Carmel Executive Park Mailing Address
Drive, Suite 310, Charlotte NC
28226
Street Address 7401 Carmel Executive Park Street Address
Drive, Suite 310, Charlotte NC
28226
Phone [phone] Phone
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 8313 Book
Page 869 Page
l0. Tax Map Parcel Number where land disturbing activity will take place 09 __ 216 __ 042
07-18 Permits. Checklists, and Fomis
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 list
additional owners)
Name Century Communities Southeast LLC Name
vlailin- Address7401 rmg? Mailing Address
Drive, Suite 310, Charlotte NC
28226
Street Address-1 60 M}ne Lake Cpff_$ i�.f�20o Street Address
Raleigh, NC 27615
Phone [phone] Phone
Fax Fax
3. 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
3
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 Parry 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
The above information is true and correct to the best of my knowledge and belief and "as 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 Johnny Evans Title Land Development Project Manager
Signature ,�;W� Date LQ 1j2q � 94OZ2
• �`
a Notary Public of the County of .State of North Carolina.
hereby certify that 3Phnr_"j1,]_ appeared personally before me this day a d being dily sHom acknowledged
that the above form was executed by him.
'Vv ��ii�FE�F h ie �ntarialseal. this 1` da! of -- Cyr .b - 262.'7—
�` •••:.csfdn 1 1.
ARYp^w' _ (Notan)
=U` My commission expires �`� 2 �.J
Uary�? ',l•, 07-19 Permits, Checklists, and Forms
Division 07
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