NCC230623_FRO Submitted_20230309

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 Autumn Drive
2. Address where land disturbing activity will take place„ 2900 Old Q d=e Higbway -M0J 02%-UC
3. Approximate date disturbing activity will commence 06 / 01 1 202
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage of land to be disturbed or uncovered 14.41
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.) 1 900.00
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Tom Mur by _ Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name Monroe AD LLC Name
Mailing Address PO Box 1150 Mailing Address
Jackson, WY 83001
Street Address, 185 W Broadway, Ste 101 Street Address
Jackson, WY 83001
Plione 307-739-2500 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 7883 Boo',
Page 843 Page
10. Tax Map Parcel Number where land disturbing activity will take place 093 01 -- 169
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE
STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part 11
Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name Intrepid Investors LLC Name
Mailing Address PO Box 1150
Jackson, V YY 830Q_1_
Street Address 185 W Broadway, Ste 101
Jackson WY 53001
Phone
Mailing Address
Street Address
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
Phone
Email
City State
Fax
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 Agent Tom Murph
Mailing Address 4023 Arbor Wa ,Charlotte, NC 28211
Street address City State Zip
Phone [phone] Email tmur h4203 mail.com fax
3. The above information is true and correct to the best ofiny knowledge and belief and was provided by me
under oath. l 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 V" r171—I °'"" a,� Title �0'�
y—e� Date
Signature
_3A- �-M —I—/-
1, .iG�a. �� 1 Notaiy
hereby certify lhal
that the above ronn %vas executed by him.
arthe County of Stoic oFNorth Carolina,
_ appeared personally before me this clay and being (lily sworn acknowledged
Witness my hand and notarial seal, this �i day of �r
W.
SEAL
Notary Public y
lredelf
County —
My Comm, l;x
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My commission cxpiaes
07-19 Permits, Checklists, and Forms
Division 07