NCC223357_FRO Submitted_20220927

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: Primrose School Relocation
Location of Land -Disturbing Activity: 614 Old Mill Village Drive; Apex, NC 27502
Approximate Date Land -Disturbing Activity will Commence: 9-19-2022
Acreage of Land to be Disturbed: 3.22
Latitude: 35.7333
Longitude: -78.8443
Land Owner(s) of R Fcord (use blank page to list additional owners):
Name:4KYL4 5.hOUIItanName
PART B
Current Mailing Address:
1^710Ia,J,.;�Oyarczn
Current Mailing Address
City, State, Zip: ZAaL&A��- �]S� City, State, Zip
Person or firm financially responsib[e (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
Telephone, E-mail:
Current Mailing Address:
J L- 2
City, State,
Street Address (if different from mailing address)
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.
Nam
Telephone:
Current Mailing Address: Street Address (if differerntfrom 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.
Nam Date:_!A L
Title or Authorjty:
a Notary Public of the County of WcLk e- , State
of North Carolina hereby certify that 11'eM—j 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
13 day of50+44 :f!l
MICHAEL P MC LLGAN
ka.&
Notary f u i
Wake Co., North Carolina
Notary My Commission Ex JM%Commission Expires Nov. 9, 2026
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:
JCI Builders
Telephone: gig-255-0285
Email:
dsmiihQcibuilders,com
Current Mailing Address:
3715 Neil
City, State, Zip: Raleigh, NC 27607
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: iJ4'10 Jm o-y Date:_ C� I \ 7 1 ' 12-
Title or Author' SCwlo t ?sO* CCA POIq
Signature:
K� a Notary Public of the County of �� 04 ��- � State of North
Carolina hereby certify that G 1 t \ SM � Y"X 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
'Myk day of i t V-4 �7C V a 0 I L
l Jl ,W
Notary
My Commission Expires
Revised 911912019 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:
ie under which the business is to bey'[ coond ed is (insert assumed ll or partnership name);
a r--vv C.frv,Sec, i L.L 7)P}� .n ifS�C .S! I/in c-i- Pt-4' .P
The names and residences and mailing addresses of all the owners of the business are (insert name and address of
each owner):
1 � Z Mo-y-l&n.- Lz�. -
IN WITNESS WHEREOF, this certificate is signed by each of the owners of said business, this day of
S ZvZ.Z .
0wner's fr m above Sign below:
State of North Carolina
County of Wake
I,AjL�Xje P V� Q 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 sea[ this 13 day of 566f&h� , ;Wa
ICHAEL P MCUdLGAN
Notary My Commission E pires Notary Public
Wake Co., North Carolina
My Commission Expires Nov. 9, 2026
Revised 9119120.19 Page 4

Name of Corporation:
7Name 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:
i
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 911912019
Page 5