NCC215684_FRO Submitted_20211019

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: The Park at Wimberly
Location of Land -Disturbing Activity: 1405, 1409, 1209, 1401 Wimberly Road and 1012 & 1000 Double Helix Road
Approximate Date Land -Disturbing Activity will Commence: Spring 2020
Acreage of Land to be Disturbed: 30
Latitude: 35.754099°
Longitude: -78.914846'
Land Owner(s) of Record (use blank page to list additional owners):
Name: See Attached
Current Mailing Address:
City, State, Zip:
PART B
Name:
Current Mailing Address
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: Envision Homes, LLC
Telephone: [phone] E-mail: iosh(a)envisionhomesnc.com
Current Mailing Address: Street Address (if different from mailing address)
4441 Six Forks Road Same
Suite 106-117
City, State, Zip: Raleigh, NC 27609 City, State, lip
Revised 312712020 Page 1

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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: Street Address (if different from mailing address)
City, State, Zip:
Signature:
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 Josh Swindell Date: / • `I • �[ 1
Title or Authority:Managing Member
Signature: +.•'�1� '
I, A"VVjee_'_ajC, aNotary Public of the County of W4, State
of North Carolina hereby certify that personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. W.
ANNALEE RICHARDSON
dayof Notary Public
North C�EA`ina
r Wake C iu'ltt y
Notary My Commission Expires
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 312712020 Page 2

PART C
Contractors and/or subcontractors (person(s) or firm(s) engaging in the land -disturbing activity):
Name Person or Firm:
Cardinal Civil Contracting
Telephone: [phone]
Email:
[e-mail]
Current Mailing Address:
4441 Six Forks Road
Suite 106-117
Name of Person or Firm:
Telephone:
Email:
Current Mailing Address
City, State, Zip: Raleigh, NC 27609 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: Jeremy Spivey
Title or AuthoAty .'resident
Signature:
Date: +
Notary Public of the County of-� 1 State of North
Carolina hereby certify that _ personally appeared before me this
day and u der oath acknowledged that the above form was executed by him/her. Witness my hand and seal this
day of 4y ANNALEE RICHARDSON
40A/] NotagfMublic
Y� North Carolina
Wake County
Notary My Commission Expires
Revised 3/27/2020 Page 3