NCC232905_FRO Submitted_20231004

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 Secrest Meadows Subdivision
2, Address where land disturbing activity will take place3903 Secrest Shortcut Road
3. Approximate date disturbing activity will commence 11 / 01 / .2023
4. Purpose of development(residential,commercial, industrial,etc.) Residential
5. Total acreage of land to be disturbed or uncovered 43 + 1.4 Ac.
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.) $500
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Joe Polite Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
Name Patrick A.&Gayle B.Secrest Name Rodney A.&Melinda T.Secrest Bryan P.Secrest
Mailing Address 3907 Secrest Shortcut Road Mailing Address 3815 Secrest Shortcut Road
Monroe,NC 28110 3901 Secrest Shortcut Road Monroe,NC 28110
Monroe,NC 28110
3907 Secrest Shortcut Road 3815 Secrest Shortcut Road
Street Address Monroe,NC 28110 Street Address Monroe,NC 28110
3901 Secrest Shortcut Road
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 426 309 Book 1618 6524
Page 777 135 Page 131 900
10. Tax.Map Parcel Number where land disturbing activity will take place 09 -- 256 -- 001
09 256 001 D
09 —256— -001J
09 -- 256 -- 001 L
07-18 Permits,Checklists,and Forms
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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 MTS CLT, LLC Name
Mailing Address 2857 Westport Road Mailing Address
Charlotte, NC 28208
Street Address Street Address
Phone [phone] Phone
Fax [phone] 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
Mailing Address
Street address City State Zip
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��sip person)
Type or Pr' IYam�lu�,F, ? it u. jl• Title VP
(71
Signature ' ' V j�./- Date / /
1, f"Ot11 in p110 t,a Notary Public of the County of Me(-Le4i L CJ .State of North Carolina.
hereby certify that 3 Ole ►t• b\1 3v . appeared personally before me this day and being dily sworn acknowledged
that the above form was executed by him.
Witness my hand and notarial seal,this II day of SectiAPA fir — 1;6
SEAL Kaitlyn Salley
NOTARY PUBLIC ( otan) L
'
T Mecklenburg County My commission expires
North Carolina 07-19 Permits, hecklists, and Forms
My Commission Expires April,27,2025
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