NCC232454_FRO Submitted_20230815

Financial Responsibility Ownership Form
Town of Boone Planning& Inspections Department e,, t
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: 675 E KING ST
Watauga County Parcel Identifications Number(s): 2910-48-0637-000 & 2910-48-1866-000
Longitude : 81 .664344 W Latitude: 36.217899 N
Approximate date land-disturbing activities will commence: 05/01/2023
Approximate acreage of land to be disturbed or uncovered: 1 .66 ACRES
Purpose of development (residential, commercial, industrial, etc.): COMMERCIAL
Has an erosion control plan been filed? ❑ Yes 0 No
Landowner(s) of record (use blank page to list additional owners):
Name: HODGES, JOHN WAISTEL III
Address: 121 CHERRY HILL RIDGE, JEFFERSON, NC 28640
Phone:
Email:
Indicate Book and Page where deed or instrument is filed:
Book: 2036 Page: 793 Book: 2282 Page: 377
Person to contact should sediment control issues arise during land-disturbing activity:
Name: DOUG BENOIT, PE
Address: 520 PROVIDENCE HIGHWAY, SUITE 9, NORWOOD, MA 02062
Phone: [phone]
Email: [e-mail]
Person(s) or firm(s) financially responsible for this land-disturbing activity:
Name: ARISTA BOONE LLC
Address: 520 PROVIDENCE HIGHWAY, SUITE 9, NORWOOD, MA 02062
Phone: [phone]
Email: [e-mail]
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North Carolina agent,for the person or firm who is financially responsible:
Name: C T Corporation System
Address: 160 Mine Lake Court, Suite 200, Raleigh NC 27615
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.
Gregory Botsivales --A.--upc-k5 �
Printed Name Title
Signature -) Date
I, Notary Public of the County of ictilt,413-12)1i2- , State
of S , hereby certify that � ec , personally appeared
before me this day under oath, acknowledging that this form was executed by him/her.
Witness my hand and seal,this j , day of ry , 202.3
T •
' ' I
Alotary Signature: A /
',
My Commission Expires: ,. NICOLETTAT. GIATRELIS
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„ �i My Commission Expires
Oct 5, 2029
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