NCC232505_FRO Submitted_20230818

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 Unionville-Indian Trail Pump Station and Force Main Replacement
2. Address where land disturbing activity will take place 2311 Unionville Indian Trail Road, Monroe,
NC 28110 (PUE located at this address)
3. Approximate date disturbing activity will commence 7 / 31 ; 2023
4. Purpose of development(residential,commercial, industrial,etc.) Residential
5. Total acreage of land to be disturbed or uncovered 9 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.) $1300.00
(1 ac x $500) + (8 ac x $100)
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Dan Rossi Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
Name See Attached Name --_----_. _--
Mailing Address Mailing Address
Street Address Street Address
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 See Attached Book
Page Page
10. Tax Map Parcel Number where land disturbing activity will take place See Attached -_
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 Pulte Home Company,LLC Name
Mailing Address 2626 Glenwood Avenue Mailing Address
Suite 550,Raleigh,NC 27608
Street Address 2626 Glenwood Avenue Street Address
Suite 550, Raleigh, NC 27608
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
Phone 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 Address
Street address City State Zip
Phone Email 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)
Type or Print Name Dan ssi Title VP Land
PPllanning and Development
Signature ,� L � Date J} / I /
.01 + ,a Notary Public of the County of KPCt afPV5 .State of North Carolina,
hereby certify that `bat-n.t_e, l OSS t appeared personally before me this day and being(lily sworn acknowledged
that the above form was executed by him. (�
Witness my band and notarial seal,this t 1 ' da% of )S4 , 20z3
Pcf344ze".4P-4.01.±-
1..,41 1, Porsha Stewart (Notary)
tf NOTARY PUBLIC My commission expires Oct 202$"
Mecklenburg County,NCB,,
07-19 Permits, Checklists, and Forms
My Commission Expires May 09,2028 Division 07