NCC232496_FRO Submitted_20230818

Financial Responsibility Ownership Formr"."\-"k'
Town of Boone Planning&Inspections Department BIt
"lTU 4rN1a:
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 a ocpnnt and i#.a question)svnot apphcableX (a e i t.` *,-§lard I N , ,
Address where land-disturbing activity is taking place: 280 E King Street
Watauga County Parcel Identifications Number(s): 2910280027000
Longitude : -81.6714 Latitude: 36.2159
Approximate date land-disturbing activities will commence: 8/2/2023
Approximate acreage of land to be disturbed or uncovered: 1.956
Purpose of development(residential,commercial, industrial,etc.): Commercial
Has an erosion control plan been filed? QI Yes U No
Landowner(s)of record (use blank page to list additional owners):
Name: Narsi Development Boone, LLC
Address: 10020 Sellona Street, Suite 100, Raleigh, NC 27617
Phone: [phone]
Email: [e-mail]
Indicate Book and Page where deed or instrument is filed:
Book: Page: Book: Page:
Person to contact should sediment control issues arise during land-disturbing activity:
Name: Chris Leonard-Omega Construction
Address: 1100 South Stratford Road, Building C, Suite 110, Winston Salem, NC NC. 27103
Phone: [phone]
Email: [e-mail]
Person(s)or firm(s)financially responsible for this land-disturbing activity:
Name: Narsi Development Boone, LLC
Address: 10020 Sellona Street, Suite 100, Raleigh, NC 27617
Phone: [phone]
Email: [e-mail]
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North Carolina agent,for the person or firm who is financially responsible:
Name:
Address:
Phone:
Email:
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.
Deven Patel Manager
Printed Name Title
8/1/2023
Signature Date
Brad tt e$L y ,a Notary Public of the County of DU P 1.0t , State
of War (aro�•nk , hereby certify that ve Paf ,personally appeared
before me this day under oath,acknowledging that this form was executed by him/her.
Witness my hand and seal,this /S4- ,day of A u q u.S4' 20.3
Notary Signature: ��I
My Commission Expires: YI Qr`
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