NCC221892_FRO Submitted_20220518

Financial Responsibility Ownership Form
Town of Boone Planning & Inspections Department N E
680 W. King Street, Suite C • Boone, North Carolina 28607
Phone [phone] • Fax [phone] • Email: [e-mail] • www.townofboone.net
No person shall initiate any land -disturbing activity covered by Town's Unified Development Ordinance Article 20 Soil
Erosion and Sediment Control prior to completing and filing this form with the Town's Planning and Inspections
Department. The financially responsible party will be on record as the party to accept any Notices of Violation or related
documents for any non-compliance of the Town's Soil Erosion and Sedimentation Control regulations. If the financially
responsible party is out of State, a North Carolina agent must be assigned.
Please type or print and if a question is not applicable, place NA in the blank.
Address where land -disturbing activity is taking place: 1996 US Hwv. 421 South Boone, NC
Watauga County Parcel Identifications Number(s): 2920-09-3240-000
Longitude : -R1 F4291 2
Latitude: 36.220232
Approximate date land -disturbing activities will commence: September 1, 2021
Approximate acreage of land to be disturbed or uncovered: 2.14
Purpose of development (residential, commercial, industrial, etc.):
rPiciPnt- ial
Has an erosion control plan been filed? ® Yes ❑ No
Landowner(s) of record (use blank page to list additional owners):
Name: The Collection on 421, LLC
Address: 215 Boone Heights Drive Suite 107 Boone, NC 28607
Phone: 070_`>G`>_a0n'7
Email: [e-mail]
Indicate Book and Page where deed or instrument is filed:
Book: 2255 Page: 875 Book:
Person to contact should sediment control issues arise during land -disturbing activity:
Name: Jason Gaston
Page:
Address:
215 Boone Heights Drive Suite 107 Boone, NC 28607
Phone:
828-262-9807
Email:
[e-mail]
Person(s) or firm(s)
Name:
financially responsible for this land -disturbing activity:
Valor Enterprises, LLC
Address:
215 Boone Heights Drive Suite 107 Boone, NC 28607
Phone:
828-262-9807
Email:
[e-mail]
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North Carolina agent, for the person or firm who is financially responsible:
Name: Jason Gaston
Address: 215 Boone Heights Drive Suite 107 Boone, NC 28607
Phone: [phone]
Email: [e-mail]
The above information is true and correct to the best of knowledge and belief and was provided by me while under oath.
This form must be signed by the financially responsible person if an Individual or by an officer, director, partner, attorney -
In -fact, or other person with authority to execute instruments for the financially responsible company or entity, if not an
individual.
on Gaston
Printed Name
Igna ure
Title
06 21 21
Date
a Notary Public of the County of�State
hereby certify that a r personally appeared
before me this day under oath, acknowledging that this form was executed by him/her.
Witness my hand and seal, this
Notary Signature:
S r day of !. 20,Z/.
- 7--c' _X_ f
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