NCC230046_FRO Submitted_20230110

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 Village at Depot 499
Location of Land -Disturbing Activity: Intersection of Apex Barbecue Rd. and S. Salem St.
Approximate Date Land -Disturbing Activity will Commence: Fall 2022
Acreage of Land to be Disturbed:15.7
Latitude: 35.721105
Longitude:-78.872209
Land Owner(s) of Record (use blank page to list additional owners):
Name: -Halle Building Group
Current Mailing Address:
56 Hunter Street #110
City, State, Zip: Apex, NC 27502
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: Halle Building Group
Telephone: [phone]
Current Mailing Address:
56 Hunter Street, Suite #110
City, State, Zip: Apex, NC, 27525
Revised 312712020
E-mail: [e-mail]
Street Address (if different from mailing address)
City, State, Zip.

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: Eric Rifkin, Assistant Vice President
Telephone: [phone]
Current Mailing Address:
56 Hunter Street, Suite #110
Street Address (if different from mailing address)
City, State, Zip: Apex, NC 27502 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.
Date:212312022
Title or Authority:Assistant Vice President
Signature:
1, �{;T� Matts�„ a Notary Public of the County of Wakes State
of North Carolina hereby certify that krc � #� fk,:► 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
23A#( day of -LA_1 ..04 zozx
0 CEP
.v.-►n ujou ►w `-l�s- 28 zo =,%gNo ary Cam fission 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:
Halle Building Group LP
Telephone: [phone]
Email:
[e-mail]
Current Mailing Address:
56 Hunter Street
Suite #110
City, State, Zip: Apex, NC 27502
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: Eric Rifkin
Title or Authority: Assistant Vice President
Signature:
2/23/2022
I, L&04n a Notary Public of the County of Wake_ State of North
Carolina hereby certify that r-_rte_ Ri'fgA'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
— 2 9AA day o /-I'\ PA&MA I AOXX
0
Nota
SEAL
Revised 312712020 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):
Halle Acquisitions LLC
The names and residences and mailing addresses of all the owners of the business are (Insert name and address of
each owner):
5
Martha D. Halle: 2900 Linden Lane, Suite 300, Silver Spring, M D 20910
IN WITNESS WHEREOF, this certificate is signed by each of the owners of said business, this oe8'�'t day of
Owner's from above Sign below:
I
State of North Carolina
County of Wake
1, +(�&thrw 6" Mattson a Notary Public, do hereby certify that on this
I j I J
f�- 0 X622- personally appeared before me Warren E. H&V& an
Mmr+V,,- "b- H--Ite
day of
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 A3 day of o,44&--y
V
Notary '
Revised 312712020 Page 4

Name mfCorporation: Halle Acquisitions LLC
Name of registered agent, street address, mailing address of registered office in Wake County:
Name: Eric Rifkin, Assistant Vice President
Street Address: 56 Hunter Street, Suite #110
C�y�a�,�p NC2�U
Current Mailing Address: 5UHunter Street, Gude#11O
City, State, Zip: Apex, mc2/xou
Enter first, middle, and last name mfprincipal officers. Enter title and street address mVprincipal officers.
Name and Title:
Name and Title:
Warren E. Halle, President
MerthoD. Halle, Owner
Street Address:
Street Address:
29UOLinden Lane, Suhe3OO
28ODLinden Lane, Suite3OO
City, State, Zip:
City, State, Zip:
Silver Spring, K8D2O01O
Silver Spring, MID 20910
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 mfdirectors. Attach pages as meueusa,V'
Name and Title:
Name and Title:
VVarnanE. Halle, Director
Martha O.Halle, Director
Street Address:
Street Address:
2SOULinden Lane, SuiVa3UO
2HOULinden Lane, GuiVe3OO
City, State, Zip:
City, State, Zip:
Silver Spring, MID 2U91O
Silver Spring, MID 2O91O
Name and Title:
Name and Title:
Street Address:
Street Address:
[by, State 3]p:
City, State Zip:
Revised3/271202O Page