NCC241105_FRO Submitted_20240412

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM p,PE,{
SEDIMENTATION POLLUTION CONTROL ACT • 1,,,
WATER RESOURCES
105-B Upchurch Street
Town of Apex, North Carolina 27502
Contact: James Misciagno
Phone: [phone] E-Mail: [e-mail]
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:Calyx Assisted Living of Apex
Location of Land-Disturbing Activity:7501 Jenks Road,Apex, NC
Approximate Date Land-Disturbing Activity will Commence:May 2024
Acreage of Land to be Disturbed:6
Latitude: 35.7550 Longitude: -78.8940
Land Owner(s) of Record (use blank page to list additional owners):
Name:Carillon Assisted Living of Apex LLC Name:
Current Mailing Address: Current Mailing Address
4901 Water's Edge Drive
City, State,Zip:Raleigh, NC 27606 City, State, Zip
PART B
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:Carillon Assisted Living of Apex, LLC
Telephone:[phone] E-mail:[e-mail]
Current Mailing Address: Street Address (if different from mailing address)
4901 Water's Edge Drive
City, State, Zip:Raleigh, NC 27606 City, State,Zip
Revised 9/19/2019 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: Street Address(if different from mailing address)
City, State,Zip: City, State,Zip
Signature:
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:Karen Moriarty Date:04/05/2024
Title or Authority:CEO '`
Signatures`
I, 04 'I d6k, aL1 ' 01- a Notary Public of the County of e e , State
�yl J
of North Carolina hereby certify that �l e n I s )Q rl Q r TL� 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 rl I a0, MELINDA B TAYLOR
Nota3E/kublic, North Carolina
t ficeldc die t.
Lee County
.i. ; My Comm County
Expires
Nota y My Cornhlission Expires = .... ' CAL
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 9/19/2019 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:
Thomas Construction GRouip
Telephone:[phone] Telephone:
Email: Email:
[e-mail]
Current Mailing Address: Current Mailing Address
1022 Ashes Drive
City, State,Zip:Wilmington, NC 28405 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:Karen Moriarty Date:04/05/2024
Title or Authority:CEO
Signature:
I, f 'l P I t (l dOC 1 > - J (,-q 67 a Notary Public of the County of e e , State of North
Carolina hereby certify that V Y n 1 ' OV 1 (,Z( 1 personally appeared before me this
dayand under oath acknowledged that the above form was executed byhim her. Witness myhand and seal this
g /
��
day of , � , 8a/A`_t
• MELINDA B TAYLOR
IaA C n / / o0a tT' .�`_ Nota�D Lee., North Carolina
71 tl_iatifiC CnY/ (/Y„ S;, y ? :j Lee County
Notary My Com ission Expires;.�4'A.lT M C� m'ssio E r
..u,....,�., l/
Revised 9/19/2019 Page 3

CERTIFICATE OF ASSUMED NAME OR PARTNERSHIP
(SEDIMENTATION POLLUTION CONTROL ACT)
The undersigned,proposing to engage in business in Wake County,North Carolina,under an assumed name or partnership
name, do hereby certify that:
The name under which the business is to be conducted is (insert assumed or partnership name):
The names and residences and mailing addresses of all the owners of the business are(Insert name and address of
each owner):
IN WITNESS WHEREOF,this certificate is signed by each of the owners of said business, this day of
Owner's from above Sign below:
State of North Carolina
County of Wake
I, a Notary Public,do hereby certify that on this day of
, , personally appeared before me
who are all signers of the foregoing instrument,and each acknowledges the due execution thereof. IN WITNESS
WHEREOF,I have hereunto set my hand and official seal this day of ,
SEAL
Notary My Commission Expires
Revised 9/19/2019 Page 4

Name of Corporation:
Name of registered agent,street address,mailing address of registered office in Wake County:
Name:
Street Address:
City,State,Zip:
Current Mailing Address:
City,State,Zip:
Enter first, middle,and last name of principal officers. Enter title and street address of principal officers.
Name and Title: Name and Title:
Street Address: Street Address:
City,State,Zip: City,State,Zip:
Name and Title: Name and Title:
Street Address: Street Address:
City, State,Zip: City,State,Zip:
Enter first, middle,and last name of directors. Enter title and street address of directors. Attach pages as necessary.
Name and Title: Name and Title:
Street Address: Street Address:
City,State,Zip: City,State,Zip:
Name and Title: Name and Title:
Street Address: Street Address:
City,State, Zip: City, State,Zip:
Revised 9/19/2019 Page 5