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HomeMy WebLinkAboutNCC232502_FRO Submitted_20230821 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 EROSI 1303 W ROOSEVELT BLVD TREE CLEARING 2. Address where land disturbing activity will take place EROSI 1303 W ROOSEVELT BLVD,MONROE,NC 28110 3. Approximate date disturbing activity will commence 9 / 1 / 2023 4. Purpose of development(residential,commercial,industrial,etc.) COMMERCIAL 5. Total acreage of land to be disturbed or uncovered 2.87 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.) $700 7. Agent to contact should sediment control issues arise during land disturbing activity Name BRUCE GRAHAM Phone 704-533-3355 8. Landowner(s)of Record(use blank page to list additional owners) Name REBPAT LEASING LLC Name Mailing Address 722 PRESSLEY RD,SUITE 101 Mailing Address CHARLOTTE,NC 28217 Street Address 722 PRESSLEY RD,SUITE 101 Street Address CHARLOTTE,NC 28217 Phone 704-533-3355 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 860 Book Page 171 Page 10. Tax Map Parcel Number where land disturbing activity will take place 0922 -- 50 -- 30A 0922 -- 50 -- 30B 0922 -- 50 -- 30C 07-18 Permits, Checklists, and Forms Division 07 CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL Part II t. Person(s)or firm(s)who are financially responsible for this land disturbing activity(use blank page to list additional owners) Name REBPAT LEASING LLC Name Mailing Address 722 PRESSLEY RD,SUITE 101 Mailing Address CHARLOTTE,NC 28217 Street Address 722 PRESSLEY RD,SUITE 101 Street Address CHARLOTTE,NC 28217 Phone 704-533-3355 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 BRUCE GRAHAM Title � 4 Signatu Date S / ZZ / Z 0 Z3 ,a Notary Public of the County of 014,4-&-ka- -- ,State of North Carolina, hereby certify that —6.4k[T,Z (v✓sF-Aa appeared personally before me this day and being(lily sworn acknowledged ootegeothat the above f'omleXt+. �utt�3S+frj QP F). . Witness my hail'and notariiall seal,thi s day of �a/ ,Z013 • • om • • • SEAL C) • �e 1G c3 (Notary) ozi , My commission expires it) •- % • �. 6 " ‘ .zt%% 07-19 Permits, Checklists, and Forms Division 07