NCC230696_FRO Submitted_20230320

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 Woodlands Creek Lots 61-75 ( for erosion control purposes only)
2. Address where land disturbing activity will take place 3238 Leah Elizabeth Lane EROSI
3. Approximate date disturbing activity will commence
05 1 01 1 2023
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage of land to be disturbed or uncovered 3.89
6. Amount of fee enclosed (fee will be the amount of current policies per acre multiplied by the total number
of acres or any pant of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $800
7. Agent to contact should sediment control issues arise during land disturbing activity
Todd Farlow
Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
9
10
Name Helmsman Homes LLC
Mailing Address PO Box 3965
Mooresville, NC 28117
Street Address 236 Raceway Dr., Suite 7
Moorseville, NC 28117
Phone [phone]
Fax
Name
Mailing Address
Street Address
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)
8564
Page 403
Tax Map Parcel Number where land disturbing activity will take place 09298418,-89298419;-09298420. 09298421, 09298422
09298423,09298424,09298425,09298426,09298427
09298428, 09298429, 09298430, 09298432
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 Helmsman Homes LLC Name
Mailing Address 236 Raceway Dr., Suite 7 Mailing
Mooresville, NC 28117
Street Address 236 Raceway Dr., Suite 7 Street
Mooresville, NC 28117
Phone [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
Email Fax
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
Mailing
Street address
Phon
City State
Zip
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 Name FaHow
Signature
Title Legal Council
Date y / & / �3
1, �C_ Oo s (—;<-I Y1 AS �& fF , a Notary Public of the County of 41Y' C L) t o State of Norih Carolina,
hereby certify that --'I—d `a-e low appeared personally before me this day and being dily sworn acknowledged
that the above form was executed by him.
and notarial seal, this day of /"" rtl Q- , �D ��
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My commission expires
Permits, Checklists, and Forms
Division 07