NCC221541_FRO Submitted_20220420

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 Windmere Drive Commercial Development
2. Address where land disturbing activity will take place 2806 Highway 74 West w
Monroe, NC 28110
3. Approximate date disturbing activity will commence 04 15 ! 2022
4. Purpose of development (residential, commercial, industrial, etc_) Commercial
5. Total acreage of land to be disturbed or uncovered 2.90 acres
b. 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 fi•om number 5. i.e. 7.28 acres equals 8 acres.) $700
7. Agent to contact should sediment control issues arise during land disturbing activity
Dame Dusty Wiederhold Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
r_
Name Monroe NC Development, LLC Name
Mailing Address474 Wando Park Blvd, Suite 205 Mailing Address
Mt. Pleasant, SC 29464
Street Address Same as mailing
Street Address
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07--18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
1. Person(s) or firms) who are financially responsible for this land disturbing activity (use blank page to list
additional owners) H2 Contracting, NameMonroe NC Development, LLC Name g, LLC
Mailing Address474 Wando Park Blvd, Suite 205 Mailing Address 731 McGilvary St
Mt. Pleasant, SC 29464 Fayetteville, NC 28301
Street Address Same as Mailing Street Address Same as Mailing
Phone [phone] Phone [phone]
Fax Fax [phone]
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
Street address
Phone
City State
Zip
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 Na N r C r�� Title �AG!1 LIr, ' TA �
Signature Datel_I�Z
1, 9)6-Me—i,4 PU1Z.fi. 0Ly-L — a Notary Public of the County of t? State of North Carolina,
hereby certify that 6IAij 4 Wll L!Q appeared personally before me this day and being difv sworn acknowledged
that the above form was executed by him.
,�`ti�iHltliflrrlTr
Witness `toNd sift py�rW*al, this day of �1
a
(Notary)
My commission expires
07-19 Permits, Checklists, and Forms
Division 07
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