NCC223283_FRO Submitted_20220920

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 9C
Location of Land -Disturbing Activity: Richardson Road @ US-64
Approximate Date Land -Disturbing Activity will Commence: August 2022
Acreage of Land to be Disturbed: 3.06 Acres
Latitude: 35 Deg. 44' 25" N
Longitude: 78 Deg. 54' 51" 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] E-mail: [e-mail]
Current Mailing Address: Street Address (if different from mailing address)
7001 Brush Hollow Road
Suite 200
City, State, Zip: Westbury, NY 11590
City, State, Zip
Revised 911912019 Page 1

If the financially responsible party is not a resident of Wake County, complete the following for an appointed agent, in
Wake County, to receive any notice, process, pleading in any action or legal proceeding arising from a violation of the
Town of Apex Soil Erosion and Sedimentation Control Ordinance. By signing below, it is agreed that any notice, process,
or pleading against the person or firm who is financially responsible for this land -disturbing activity may be served on
the undersigned and shall be of the same force and effect as if served on the financially responsible person or firm. The
intent of this provision is to establish the presumption that the constructive notice from the Town of Apex will be
addressed through the undersigned agent.
Name:
Telephone:
Current Mailing Address:
City, State, Zip:
Signature:
Street Address (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:David K. Schmidt Date:
Mana r - E1 Holdings, LLC
Title or Aut FforiW:
Signature: ` V V V V `-A...................
I, JaA.Ie VJ • Axr m 07, a Notary Public of the County of VV�h'Q .State
of North Carolina hereby certify that Dco �� • ' Yl to dt 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
i day of 2,0 22, JANE W JARMON
NOTARY BEIAUC
Wake County
L 2 Z Wy Commission E afres Se tember28. 2022
Not My Commission Ex. P
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

PART C
Contractors and/or subcontractors (person(s) or firm(s) engaging in the land -disturbing activity):
Name Person or Firm:
Watkins Site Development - Kevin Vandy
Telephone: [phone]
Email:
kvandy@a watkinssitedevelopment.com
Current Mailing Address:
1 Centerview Dr. Rockingham Bldg, Suite 305
City, State, Zip: Greensboro, NC 27407
Name of Person or Firm:
Telephone:
Email:
Current Mailing Address
City, State, Zip
The information contained in this form is true and correct to the best of my knowledge and belief was provided by me
while under oath. (This form must be signed by the person or firm engaging in the land -disturbing activity of an
individual or by an officer, director, general partner, attorney -in -fact, or other person with authority to execute
instruments for the entity engaging in the land -disturbing activity if not an individual. I agree to provide corrected
information should there be any change in the information provided herein.
Name: Kevin Vandy Date: 8/112022
Title or Authority: Managing Member - Watkins Site Development
L
Signature:
�nt
L� �1 0 a Notary Public of the County of Seas c3 , State of North
Carolina hereby certify that kei„V\� 11G )y _ personally aj�*iYAVAfiYp fne this
day and under oath acknowledged that the above form was executed by him/her. Witne,,s Adin��ftois
�� '� ;•'�iSSip� ;s%�i
::1 day of Zak sa0TAig
Notary My Commission Expiredof
Op
'0" 0 9p
Revised 911912019 Page 3

CERTIFICATE OF ASSUMED NAME OR PARTNERSHIP
(SEDIMENTATION POLLUTION CONTROL ACT)
The un signed, proposing to engage in business in Wake County, North Carolina, under an assu/nampartnership
name, d reby certify that:
The name un r which the business is to be conducted is (insert assumed or partnership name)
The names and res nces and mailing addresses of all the owners of the business are (Ins name and address of
each owner):
IN WITNESS WHEREOF, this certificate is sig by each of the o rs of said business, this day of
Owner's from above Sign below:
State of North Carolina
County of Wake
a Notary Public, do here
personally appeared before me
fy that on this
who are all signe f the foregoing instrument, and each acknowledges the due exec here WHEREOF, I e unto set my hand and official seal this day of
otary
My Commission Expires
day of
thereof. IN WITNESS
SEAL
Revised 911912019 Page 4

Na of Corporation:
Name registered agent, street address, mailing address of registered office in Wake County:
Street dress:
City, Stat ip:
Current Maili do
City, State, Zip:
Enter first, middle, and last
Name and Title:
Street Address:
City, State, Zip:
of principal officers. Enter title and stre/adss of principal officers.
Nameand
Street re
Ci State, Zip:
Name and Title:
JF Name and Title:
Street Address:
Street Address:
City, State, Zip:
' y, State, Zip:
Enter first, middle, and last name of direc
of directors. Attach pages as necessary.
s. Enter title and stre\anitle:
Name and Title:
Na
Street Address:
Street Address:
City, State, Zip:
City, State, Zip: Nk
Name and Z.
Name and Title:
Street dress: Street Address:
Id9X1912019
tate, Zip: City, State, Zip:
Revage 5