NCC243558_FRO Submitted_20241122

Financial Responsibility Ownership Form
Town of Boone Planning& Inspections Department
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: 1111 Hwy 105,Boone,NC 28607
Watauga County Parcel Identifications Number(s): 2910-13-6480-000&2910-13-8236-000
Longitude : N 36° 12'11.24" Latitude: W 81°40'18.41"
Approximate date land-disturbing activities will commence: 6/1/2024
Approximate acreage of land to be disturbed or uncovered: 1.436 AC.
Purpose of development(residential, commercial, industrial, etc.): Commercial
Has an erosion control plan been filed? ❑Yes ❑ No
Landowner(s) of record (use blank page to list additional owners):
Name: Boone Land Properties,LLC
Address: P.O.Box 700,Claremont, NC 28610
Phone: [phone]
Email: [e-mail]
Indicate Book and Page where deed or instrument is filed:
Book: 1864 Page: 447 Book: NA Page: NA
Person to contact should sediment control issues arise during land-disturbing activity:
Name: Kelly Wagoner-Foresite Group/Site contractor is TBD
Address: 3740 Davinci Ct.,Suite 100
Phone: [phone]
Email: [e-mail] and [e-mail]
Person(s)or firm(s) financially responsible for this land-disturbing activity:
Name: Halle Properties,L.L.C.
Address: 20225 N Scottsdale Road,Scottsdale,AZ 85255
Phone: [phone]
Email: [e-mail]
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North Carolina agent, for the person or firm who is financially responsible:
Name: Danielle Faust-Corporation Service Company
Address: 2626 Glenwood Avenue,Suite 550
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.
Bridget Kautzky Agent
Printed Name Title
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Signature Date
Donna M Warner , a Notary Public of the County of Maricopa ,State
of Arizona , hereby certify that Bridget Kautzky , personally appeared
before me this day under oath, acknowledging that this form was executed by him/her.
Witness my hand and seal,this , day of t/e tbf.L , 20"'1 .
Notary Signature:
My Commission Expires: 7 'G .44'S
S:\FORMS\PI_Forms_Current\Zoning Forms\FinancialResponsiblityForm_07012019.doc
Donna M Warner
Notary Public
j Maricopa County,Arizona
My Comm.Expires 04-06-28
Commission No.664588
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