NCC240292_FRO Submitted_20240201

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
I. Name of Project 2904 Stitt Street
2. Address when, land disturbingactivitywill rake 2-904 Stitt Street
place ---
3. Approximate date disturbing activity will commence 7 1 ;_ 2023
4. Purpose of development(residential,commercial,industrial.etc.)_ Commercial
5. Total acreage of land to be disturbed or uncovered 4 .25
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.)4 2 5=90 0. 00
7. Agent to contact should sediment control issues arise during land disturbing activity
Kirby Crooke 704 . 957 .5877
Name _-- Phone
8. Landowner(s)of Record(use blank page to list additional owners)
Kiby Crooke 6 spouse Mary Jane Crooke
Name Name
MailingAddress 2805 Walkup Av
Mailing Address
Suite A, MOnroe, NC 28110
Street Address 2805 Walkup Av
Street Address
Suite A, 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 8358
Book
0223
Page Paste
10. Tax Map Parcel Number where land disturbing activity will take place 091 15 004
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 Kirby Crooke Name
Mailing Address 2709 Walkup Av Mailing Address
Monroe, NC 28110
Street Address Street Address
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
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 person)
Type or Print a e Kirby Crooke Title Owner
Signature Date 10 / 10 / 2023
tary Public of the County of MQ.e ref ou_r _,State of North Carolina,
•
hereby certify that ('I01�.,..__. l .t Q..._._ appeared personally before Inc thiti ef:iy and being(illy sworn acknowledged
that the above form was executed by him. Ij Witness my hand`,ctixfR RO .4h'.._.....IU._—_.day of__ Le . 623
SI:AI. • GF
r • ROTARY •;y= (Notary)
•
• c• ar`••: PU I C My commission expires 7�p/ — _
n B� •�' 07-19 Permits, Checklists, and Forms
••••••••'••; . Division 07
-BERG