NCC220432_FRO Submitted_20220124

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 Braemar Village
2. Address where land disturbing activity will take place 18 14 N. Charlotte Ave.
3. Approximate date disturbing activity will commence �09_/_01 / 2021
4. Purpose of development (residential, commercial, industrial, etc.)_ Residential
5. Total acreage of land to be disturbed or uncovered 12.10
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.) $1700.00
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Johnathan McCall Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name Dickerson Blvd LLC Name
Mailing Address_309 Post Office Rd._ Mailing Address_
Indian Trail, NC 28079
Street Address 309 Post Office Rd. Street Address
Indian Trail, NC 28079
Phone [phone] 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 6498 Book
Page 025 Page
10. Tax Map Parcel Number where land disturbing activity will take place 092___ 640 __ 23B
07-1.8 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
1. Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name Carolina Development Services, LLC Name
Mailing Address 280 Unionville Indian Trail Rd Mailing Address
Indian Trail, NC 28079
Street Address 280 Unionvillf Indian Trail Rd Street Address
Indian Trail, NC 28079
Phone [phone] Phone
Fax Fax
A) If the Financially Responsible Party is not a resident of North Carolina, give name and address of a North
Carolina Agent
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
Current Mailing Address
Email Address
Current Street Address
City State Zip City State Zip
Phone# 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 Pri a e Johnathan McCall Title Manager
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hereby certify that ���n �� rv� • r V\-- 7 Q ` (appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him.
Witne hand and notarial seal, this
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Permits, Checklists, and Forms
Division 07