NCC222990_FRO Submitted_20220823

No person may initiate any land -disturbing activity on twenty (20) thousand square feet or more before this form has been
completed and filed with the Town of Apex Water Resources Department.
PART A
Name of Project: Sweetwater - Phase 10 (Early Grading and Stage 1 Erosion Control Plan)
Location of Land -Disturbing Activity: Richardson Road @ US-64
Approximate Date Land -Disturbing Activity will Commence: February 2022
Acreage of Land to be Disturbed: 11.45acres (221 Acres Previously Approved)
Latitude: 35 Deg. 44' 34" N
Longitude: 78 Deg. 55' 00" W.
Land Owner(s) of Record (use blank page to list additional owners):
PART B
Name: KEPE1 Holdings, LLC
Current Mailing Address:
7001 Brush Hollow Road
Suite 200
Name:
Current Mailing Address
City, State, Zip: Westbury, NY 11590 City, State, Zip
Person or firm financially responsible (developer) for this land disturbing activity. Financial responsibility includes, but
may not be limited to: payment of civil fines and criminal penalties and any other costs associated with bringing the
project into compliance with the Town of Apex Soil Erosion and Sedimentation Control Ordinance.
Name of Person or Firm: KEPE1 STC, LLC
Telephone: [phone]
Current Mailing Address:
7001 Brush Hollow Road
Suite 200
E-mail: [e-mail]
Street Address (if different from mailing address)
City, State, Zip: Westbury, NY 11590 City, State, Zi
Revised 911912019 Page 1

financially responsible party is not a resident of Wake County, complete the following for an appoint nt, in
Wak ty, to receive any notice, process, pleading in any action or legal proceeding arising from tion of the
Town of Ap Erosion and Sedimentation Control Ordinance. By signing below, it is agreed t y notice, process,
or pleading again erson or firm who is financially responsible for this land -disturb' ivity may be served on
the undersigned and sh f the same force and effect as if served on the financeicefrcm
sponsible person or firm. The
intent of this provision is to ish the presumption that the constructs the Town of Apex will be
addressed through the undersigne
Name:
Telephone:
Current Mailing Address:
ip:
re:
Street (if different from mailing address)
City, State, Zip
If the financially responsible party is a partnership or other person engaging in business under an assumed name, complete
Page 4 of this form, or attach a copy.of the Certificate of Assumed Name or Partnership as recorded in the Register of
Deeds. If the financially responsible party is a corporation, complete the information on Page 5 of this form and submit a
current copy of the Annual Report as filed with the Secretary of State.
The information contained in this form is true and correct to the best of my 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, or registered agent with authority to execute instruments for a corporation or partnership if it is the
financially responsible party). I agree to provide corrected information should there be any change in the information
provided herein.
Name
Title or
Signatu
David K. Schmidt
Date: (2� ' Zg.— 2so 2Z
I, J LT uu . J ar m o-, a Notary Public of the County of `e , State
of North Carolina hereby certify that bcw I a k • �c �w d t" personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my hand and seal this
day of J U we— , 2_0ZZ
Qq_AA) I 4��
Not
JANE W.
NOTARY PUBLIC MO
My Commission Exp res Wake County
North Carolina
My Commission Expires September28, 2022
Financial responsibility encompasses personal liability by the person signing this disclosure form, if a partner in a
partnership or if an officer or director of a corporation which is either: (a) dissolved lawfully under North Carolina statutes:
(b) suspended from transacting business in North Carolina by the North Carolina Secretary of State; (c) insolvent; (d) in
bankruptcy; (e) undercapitalized to the extent it is unable to comply with the Soil Erosion and Sedimentation Control
Ordinance; or (f) a "shell' corporation.
Revised 911912019 Page 2