NCC230250_FRO Submitted_20230214

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 ""G""'y `V I r V" "G - r " CIO
C '
2. Address where land disturbing activity will take place 384 Deese Road, Monroe, NC 28110
3. Approximate date disturbing activity will commence 12 1 / 2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage of land to be disturbed or uncovered 57 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.) $6,100.00
(1 ac x $500) + (56 ac x $100)
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Tim Coey 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
N
10
Phone Phone
Fax Fax
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)
See Attached Q_^t-
Page Page
Tax Map Parcel Number where land disturbing activity will take place See Attached
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MON8OC STANDARD SPECIFICATIONS AND DETAIL MANUAL
YadU
lPurmu(o)orOnnhVwho are finunuiuUyresponsible for this land disturbing activity (use blank page ^nlist
oddi,kzno|
Name KB Home Charlotte, Inc. Nam
Mailing Address 1O000vMlsmreBoulevard, Gvhe7ou Mailing Address
Los Angeles, CA 90024
Street Address 1»e»u«wlshireBoulevard, Suite 700
Los Angeles, CA 90024
Phonco1S-7ou-7S80
Fax
Street Address
/4|fthe Financially Responsible Party isnot uresident ofNorth Carolina, give name and address ofuNorth
Carolina Agent
Name of Registered Agent Corporation Service Company
��G��dmm���o�n��NC��
Mailing AddressStreet address City State
Phone 1-800*27-9800
Ernai
Zip
13) If the Financially Responsible Party is a Partnership or other person engaging in business undervnmmvmod
nume,attach ncopy nfthe Certificate vfAssumed Namo. |ythe Financially Responsible P^nyi,a
Corporation, give the nanie and street address of the Registered Agent:
Name of Registered Agen
Mailing Address
Street address city State Zip
Email
The above in[onna|iuniatrue and correct mthe best ofmyknowledge and belief and was provided bymc
under oath. |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 ail individual or Ii is attorney in fact,
or if not un individual, by an officur, director, partner, or registered agent with authority to execute instruments
for (lie financially responsible person)
Type or hu�aTe|NJse|ick Title Division President Charlotte
Signature mute
a Notary Public of the County of' Stale of'North Carolina,
hereby cert i Fy that appeared personally bef'ore me this day and being dily Sworn acknoNvIcciged
that the above Ibmi was executed by him.
Witness my liand and notarial Seal, this day of
NOTARY PUBLIC �(N 4oi - y 4)
Gaston County -'ZV
North Carolina My commission expire A-f2a 26---
Division 07

NUMBER
PROPERTY OWNER
PIN
DEED
BOOK
PAGE
1
Wellington Monroe, L.P.
09-177-023
8607
691
2
Wellington Monroe, L.P.
09-177-030B
8607
699
3
Wellington Monroe, L.P.
09-177-023C
8607
717
4
Wellington Monroe, L.P.
09-177-023B
8607
725
5
Wellington Monroe, L.P.
09-177-023D
8607
725
6
Wellington Monroe, L.P.
09-177-024F
8607
733
7
Wellington Monroe, L.P.
09-177-024G
8607
733
8
Wellington Monroe, L.P.
09-177-024E
8607
743