NCC231540_FRO Submitted_20230522

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 American Wick Drain -35,640 SF Building Addition
2. Address where land disturbing activity will take place 1209 Airport Road, Monroe,NC 28110
3. Approximate date disturbing activity will commence 01 / 02 / 2023
4. Purpose of development(residential,commercial,industrial,etc.) Commercial
5. Total acreage of land to be disturbed or uncovered 2.38 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.) $700.00
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Doug Helms Phone [phone]
8. Landowner(s)of Record (use blank page to list additional owners)
Name C& M No. 1 Investment Partnership Name
Mailing Address 1209 Airport Road Mailing Address
Monroe,NC 28110
Street Address 1209 Airport Road Street Address
Monroe,NC 28110
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 1007 Book
Page 0322 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09 -- 369 -- 007D80
09 -- 369 — 007D90
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
I. Person(s)or firm(s)who are financially responsible for this land disturbing activity(use blank page to list
additional owners)
Nane American Wick Drain Name
Mailing Address 1209 Airport Road Mailing Address
Monroe,NC 28110
Street Address 1209 Airport Road Street Address
Monroe,NC 28110
Phone ( 704 ) 641 - 3044 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
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 Email Address
Current Mailing 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 Prin am .Scott Morris Title President
Signature ,tom/ Z
Date 4/ / S / Z Z
1, Q `) f--e✓ --.%`Q7 ,a Notary Public of the County of k.kr);U n ,State of North Carolina,
hereby certify that . S c o{i MU f r: } appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him.
Witness my hand and notarial seal,this�i 1�+�� day of f�\c.\ a o..'
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SEAL ��„'�`r�R B�!( % Q
��: OTAR1':``•``> (Notary)
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�-,�'/0 .........N-C -s•: 07-19 Permits, Checklists, and Forms
•�,�11 CCA)", ` Division 07