NCC232331_FRO Submitted_20230804

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 Monroe Airport Hangar
2. Address where land disturbing activity will take place 1420 Aviation Drive
Monroe, NC 28110
3. Approximate date disturbing activity will commence 08/01/2023/
4. Purpose of development(residential,commercial, industrial,etc.) Industrial (Aircraft Hangar)
5. Total acreage of land to be disturbed or uncovered 1.11
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.) $600.00
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Drew Boggs Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
Name City of Monroe Name
Mailing Address300 W. Crowell St. Mailing Address
Monroe, NC 28112
Street Address 300 W. Crowell St. Street Address
Monroe, NC 28112
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 1298 Book
Page 025-029 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09369005E
07-18 Permits, Checklists, and Forms
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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)
NameCharlotte Monroe Hangar 1, LLC Name
Mailing Address P.O. Box 1609 Mailing Address
Monroe, NC 28111-1609
Street Address 1613 W. Roosevelt Blvd. Street Address
Monroe, NC 28110
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 Party is a
Corporation,give the name and street address of the Registered Agent:
Name of Registered Agent Northwest Registered Agent Service, Inc.
Mailing Address 4030 Wake Forest Rd., STE 349 Raleigh NC 27609
Street address City State Zip
Phone [phone] Email 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 Print Na eKevin J. Haves, Jr. Title Manager
Signature Date 07 27 / 2023
l Hannah L. Rushing ,a Notary Public of the County of Union State of North Carolina,
hereby certify that Kevin J. Hayes, Jr. appeared personally before me this day and being ddy sworn acknowledged
that the above form was executed by him.
Witness my hand and notarial seal,this 27 day of JUIy 12023
ANNAH L RUSHING
NOTARY PUBLIC (Notary)
Union County 6-20-2024
North Carolina My commission expires
My Commission Expires June 20,2024 07-19 Permits, Checklists, and Forms
Division 07