NCC231470_FRO Submitted_20230516

Financial Responsibility Ownership Form
Town of Boone Planning&Inspections Department us ^
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: Moonstruck Lane (off Archie Carroll Road)
Watauga County Parcel Identifications Number(s): 2921-52-6311-000
Longitude : 36.228999 Latitude: _81.626200
Approximate date land-disturbing activities will commence: Spring 2023
Approximate acreage of land to be disturbed or uncovered: 1.15 Acres
Purpose of development(residential, commercial, industrial, etc.): Institutional - Patient Care Unit
Has an erosion control plan been filed? ®Yes U No
Landowner(s) of record(use blank page to list additional owners):
Name: AMOREM (Formerly known as Caldwell Hospice and Palliative Care, Inc.)
Address: 902 Kirkwood Street NW Lenoir NC 28645
Phone: [phone]
Email: [e-mail]
Indicate Book and Page where deed or instrument is filed:
Book: 2069 Page: 535 Book: Page:
Person to contact should sediment control issues arise during land-disturbing activity:
Name: April Moore, AMOREM (formerly known as Caldwell Hospice and Palliative Care, Inc.)
Address: 902 Kirkwood Street NW Lenoir NC 28645
Phone: [phone]
Email: [e-mail]
Person(s)or firm(s)financially responsible for this land-disturbing activity:
Name: AMOREM (formerly known as Caldwell Hospice and Palliative Care, Inc.)
Address: 902 Kirkwood Street NC Lenoir NC 28645
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.
Cathy Swanson CEO
Printed Name Title
af,-3‘5°1 `` — `- 2
-tun Date
I; Y I L• f A®ilY' , a Notary Public of the County of CAM W'!_-{A , State
of ICI CGf en( 1'. , hereby certify that (ot,`( /u/J CWart C Y1 , 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 MGtk- , 20 Z 3.
°e°°\\°`•\'1L moo°°°°ice Notary Signature: � ���`
Q .p�,,�w rY g � C/v
N- Notary Public G0
Caldwell
F. County _ My Commission Expires: (Q f 1 l/23
x My C•mm. Exp. !
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