NCC220835_FRO Submitted_20220222

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: 2.21 acres
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] 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

financially responsible party is not a resident of Wake County, complete the following for an appointed ,. nt, in
Wak ty, to receive any notice, process, pleading in any action or legal proceeding arising from ration of the
Town of Ap Erosion and Sedimentation Control Ordinance. By signing below, it is agreed y notice, process,
or pleading again _...person or firm who is financially responsible for this land -disturb' �ivity may be served on
the undersigned and shi t -nf the same force and effect as if served on the finance" _sponsible person or firm. The
intent of this provision is to sh the presumption that the constructiv, 4oce from the Town of Apex will be
addressed through the undersig���:, •t,
Na
Telephone:
Current Mailing Address:
Streeter (if different from mailing address)
City. Zip: City, State, Zip
S°- ,,,are:
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: Z.
f
Title or AuthporityPanager o K;EP�l Moldings, LLC _
v
Signature`'-___._�r_� P.-)
I, I 4 &. f,r" I a Notary Public of the County of " `'— " ,State
of North Carolina hereby certify that iL . "�. /iW1l c personally appear (kobt 'emr4j; this
day and under oath acknowledged that the above form was executed by him/her. Witness n!!�41,
YGt day of J (7210
®TAN �-
Notary My Commission Expires o
Financial responsibility encompasses personal liability by the person signing this disclo?44j, ,'ft� jf a paw ��P�ir%
partnership or if an officer or director of a corporation which is either: (a) dissolved lawfully unc%i r E t#t�es:
(b) suspended from transacting business in North Carolina by the North Carolina Secretary of Sta%►I(�b�in�pL�l�,�(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: Name of Person or firm:
Watkins Site Development, LLC - John Watkins Jr.
Telephone: [phone]
Email:
[e-mail]
Current Mailing Address:
1 Centerview Drive, Suite 305
Telephone:
Email:
Current Mailing Address
City, State, Zip: Greensboro, NC 27407 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: John Watkins Jr. Date: W 3 / 4m—
Title or AuthorAv-Vanaging Member -Watkins Site Development
Signature:
a Notary Public of the County of kzl �G i a. . State of North
Carolina hereby certify that n n 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
?L_day of���Gty Inz z ���� G1IA` Ari1l�401i
YiCtC �.
Notary
1>1
My Commission Expires, QJ V° p ,q �'; O
• GCD
G to 'OU84.� ? �
e
p Cw6�
�lal
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