NCC230488_FRO Submitted_20230224

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 BTR at Monroe
2. Address where land disturbing activity will take place 3424 West Highway 74, Monroe, NC 28110
3. Approximate date disturbing activity will commence 11 1 01 1 2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential Subdivision
5. Total acreage of land to be disturbed or uncovered 22 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.) $2,600.00
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Megan Ledbetter Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name BTR at Secrest Price, LLC Name
Mailing Address Mailing Address
4900 North Scottsdale Road, Suite
2000, Scottsdale, AZ 85251
Street Address Street Address
4900 North Scottsdale Road, Suite
2000, Scottsdale, AZ 85251
Phone [phone] 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 8466 Book
Page 567 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 -- 298 -- 068K
07-18 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 BTR at Secrest Price, LLC Name
Mailing Address
4900 North Scottsdale Road, Suite
2000, Scottsdale, AZ 85251
Street Address
176 Mine Lake Court, Ste. 100, Raleigh,
NC 27615
Phone [phone]
Mailing Address__
Street Add
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 Tyler Kaushagen
Mailing Address
176 Mine Lake Court, Suite 100, Raleigh, NC 27615
Street address
Phone [phone]
City State
Email Fax
Zip
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_ou
Signature
Title k,4ff^6r1a49 A5f-, -
Date J_0_ 1 " 1 zos'2,
1._CAjCD,�J_J�e ,tL �, n Notury Public ofthe County of ' V'State ol'North Carolina,
hereby certify lhal �u S appeared personally before me this day and eing ddy sworn acknowledged
that the above f'onn was a esnrled by him.
yi40yl and notarial seal, this _ day of
=M ��,�7
�� 4�G My commission expires S IX -
7
08
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07-19 Perm it ,Checklists, and Forms
���i �i�'•+:.�•'�ti3�ti�� Division 07