NCC223159_FRO Submitted_20220913

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 camp Sutton ivimea use
2. Address where land disturbing activity will take place
3.
4.
5.
6.
7
8.
372 Acme Drive
Approximate date disturbing activity will commence 08 / 14 / 2022
Purpose of development (residential, commercial, industrial, etc.) MIX -use
Total acreage of land to be disturbed or uncovered 23.91
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.) $2, 800
=$500 + (24-1)(100))
Agent to contact should sediment control issues arise during land disturbing activity
Name Tom Crouch Phone [phone]
Landowner(s) of Record (use blank page to list additional owners)
Name UC QOZB I, LLC Name
Mailing Address 231 Postage Way Mailing Address
Indian Trail, NC 28079
Street Address
704-882-1700
Street
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 8147 8147 Book 8104
Page 0151 166 page 0696
10. Tax Map Parcel Number where land disturbing activity will take place 09 _ 122 001
09 __ 117 __ 008
09 122 002
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
l . Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name UC QOZB I, LLC Name
Mailing Address 231 Post Office Rd Mailing Address
Indian Trail, NC 28079
Street Address 231 Post Office Rd Street Address
Indian Trail, NC 28079
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 Part), is a
Corporation, give the name and street address of the Registered Agent:
Name of Registered Agent Dennis Moser
Mailin- Address 231 Post Office Dr Suite B8 Indian Trail, NC 28079
Street address City State Zip
704-882-1700
Phone Email YwoS21�J`�aYV•o5p ax
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
Signatu
M
Title nK ^Lm eV mo- L
Date 9 1� T
I'h 0 A01 QP t-.' irte-' �. a Notary Public ofthe Cotmty of�iK/(it C(t' State ot'North Carolina.
hereby certify that _CtAt/��5_,—I_1LA2_5eA/ appeared personally before me his day and being ddy sworn acknowledged
that the above limn was executed by hiie—L-daN
Witness my hand and notarial seat. this ofAU41k
SIA . RAENAE H. LITTLER
NOTARY PUBLIC (Notary)
County North �t
r , 1 - 70 7-�
North Carolina � commission expires L-�- /
My Commission Expires April 16, 2022
07-19 Permits. Checklists. and Forms
Division 07