NCC223218_FRO Submitted_20220914

� Skyline Terrace
Financial Responsibility Ownership Form
Town ofBoone Planning 0\Inspections Department
6OUW.King Street, Suite C*Boone, North Carolina ZV607 ~~
Phone (82NZG8'696O*Fax (8Z8)Z68-69G1*Email: 0
No person shall initiate any land -disturbing activity covered bvTown'sUnified Development Ordinance Article 2O Soil
Erosion and Sediment Ozntn)| 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 isout ofState, aNorth Carolina agent must beassigned.
Address where land -disturbing activity istaking place: 141 Marich1ane Boone, NC
Watauga County Parcel |dentificotionsNumber(s): See attachment
Longitude: -8I.656G94
Latitude: 36.221.7
Approximate date land -disturbing activities will commence:
Approximate acreage ofland tobedisturbed o,uncovered. x on
Purpose of development (residential, commercial, industrial, etc,):
Has an erosion control plan been filed? W Yes Q No
Landmmnmf6ofrecord (use blank page tolist additional owners):
Address:
Email: zaboartnero@hu±maiI-com
Indicate Book and Page where deed or instrument is filed:
Book: 2152 Page: 749 Book: Page:
Person to contact should sediment control issues arise during land -disturbing activity:
Name: Randy Dixon
Address: 1515 YV CORW3LLIS DRIVE GDEE0GBOBD, NC 27408
Phone: [phone]
Email: [e-mail]
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Address: 1515 lW COB9QALLZ8 DRIVE GREENSBDRO, NC 27408
Phone:
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North Carolina agent, for the person or firm who is financially responsible:
Name: Randy Dixon
Address: 1515 W CORWALLIS DRIVE GREENSBORO, NC 27408
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.
Randy Dixon
Printed Name
nature
7 CA r i/, o
Title
Date
a Notary Public of the County of GU" �TY R �`> State
of �1� }� }� �r .� 1`�r crti hereby certify that —� -\ , " 6 ,{Z personally appeared
before me this day under oath, acknowledging that this form was executed by him/her.
Witness my hand and seal, this 'i ' \ day of �r� r 20
Notary Signature: —. .
My Commission Expires:
S:\FORMS\PI_Fbrms_Current\Zoning Forms\Financia[ResponsiblityForm_07012019.doc
JODY C. LONGWILL
Notary Public
North Carolina
Guilford County
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