NCC242184_FRO Submitted_20240718

Financial Responsibility Ownership Form (A7Aks
Town of Boone Planning& Inspections Department g
riE
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 and-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: Intersection of US Hwy 421-S& Bub Teems Road
Watauga County Parcel Identifications Number(s): 2920-09-6331-000,2920-09-7251-000,2920-09-6177-000&2920-09-7187-000
Longitude : W 81°38' 29.4675" Latitude: N 36° 13' 12.4842"
Approximate date land-disturb ng activities will commence: September 1, 2024
Approximate acreage of land to be disturbed or uncovered: 3.01 Ac
Purpose of development(residential,commercial, industrial,etc.): Commercial
Has an erosion control plan been filed? 18I Yes O No
Lardowner(s)of record(use blank page to list additional owners):
Name: Bub Teems Boone, LLC
Address: 606 Southstone Drive, Matthews, NC 28104
Phone: [phone]
Email: [e-mail]
Indicate Book and Page where deed or instrument is filed:
Book: 2365 Page: 939 Book: Page:
Person to contact should sediment control issues arise during land-disturbing activity
Name: Jay Shah
Address: 5000 Mackay Road, Greensboro, NC 27407
Phone: [phone]
Email: [e-mail]
Person(s)or firm(s)financially responsible for this land-disturbing activity:
Name: Mansa Hospitality Boone, LLC
Address: 4205 Cabarrus Court East, Greensboro, NC 27407
Phone: [phone]
Email: [e-mail]
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rth Carolina agent,for the person or firm who is financially responsible:
Narfie:
Address:
Phone:
Email:
above information is true and correct to the best of knowledge and belief and was provided by me while under oath.
form must be signed by the financially responsible person if an individual or by an officer,director, partner,attorney-
act, or other person with authority to execute instruments for the financially responsible company or entity, if not an
vidual.
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Printed Name Title
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Signature Date
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a NotaryPublic of the Countyof State
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"16`1n l rot (na , hereby certify that C win allh , personally appeared
)re me this day under oath, acknowledging that this form was executed by him/her.
less my hand and seal,this ,day of Ayr )) , 20 24
Notary Signature: C(01-1—
•
My Commission Expires: I `"0 . i 244)
S.\FORM PI_Forms_Current\Zoning Forms\FinancialResponsiblityForm_07012019.doc
ASHTON CARTER
Notary Public-North Carolina
Guilford County
My Commission Expires August 12.2026
•
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