NCC230623_FRO Updated Form_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 Charlotte Highway, Monroe�NG
3. Approximate date disturbing activity will commence 06 / 01 / 2021
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 Murphy Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name Monroe AD. LL
Mailing Address PO Box 1150
Jackson, WY 83001
Street Address 185 W Broadway, Ste 101
Jackson, WY 83001
Phone [phone]
Name
Mailing Address
Street Address
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 7883 Book
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
2.
Part II
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, WY 63001
Street Address 185 W Broadway, Ste 101
Jackson, WY 83001
Phone [phone]
Mailing
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 Address
Street address
City State
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 Murphy
Mailing Address 4023 Arbor Way, Charlotte, NC 28211
Street address City State Zip
Phone [phone] Email tmurph4203(q)_gmail.com 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) .46, ae—
Type or Print Name 'J&A-,VAuA�V Title t �C11J I Tii �L aPebC�r �C
Signature ���`^ ' '—� Date
1, �l re � 1 l S �' a Notary Public of the County of �� r !< 1 l i State of North Carolina.
hereby certify that -T A, Al V kJ I f appeared personally before me this day and being lily swom acknowledged
n.
2 'q day of v41
(Notary)
My commission expires
07-19 Permits, Checklists, and Forms
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