NCC230839_FRO Submitted_20230328

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: Old Mill Village - Lot 5
Location of Land -Disturbing Activity: 0 Old Mill Village Drive
Approximate Date Land -Disturbing Activity will Commence: May 1, 2020
Acreage of Land to be Disturbed: 1.1
Latitude: 35.4354
Longitude: -78.5025
Land Owner(s) of Record (use blank page to list additional owners):
Name: Town of Apex
Current Mailing Address:
PO Box 250
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: North Carolina 11 LP
Telephone: [phone]
Current Mailing Address:
56 Hunter Street, Suite 110
City, State, Zip: Apex, NC 27502
E-mail: [e-mail]
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.
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). 1 agree to provide corrected information should there be any change in the information
provided herein.
Name: �(i c R1XLci✓t Doti i o� k A, "Jl ,.L ate:
Title or Authority: S s , s %ter,-} 1L%i Ie_ Prl� 1 4Qr.
C,
Signature: e
I, "CA1. a Notary Public of the County of State
of North Carolina hereby certify that CM c. ?NS_V,,r. V , . personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my ha�rt►N �
>"`(
?, day of
Notary My Commission Expires
p'/BLIG
Financial responsibility encompasses personal liability by the person signing this disclosure form,"%%n`�}�jAjtNi i 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 911912019 Page 2

PART C
Contractors and/or subcontractors (person(s) or firm(s) engaging in the land -disturbing activity):
Name Person or Firm:
Not Known at This Time
Telephone:
Email:
Current Mailing Address:
Name of Person or Firm:
Telephone:
Email:
Current Mailing Address
City, State, Zip: City, State, Zi
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. 1 agree to provide corrected
information should there be any change in the information provided herein.
Name:
Title or Authority:
Signature:
Date:
1, a Notary Public of the County of , 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. Witness my hand and seal this
day of
Notary
My Commission Expires
SEAL
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:
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
Owner's from above Sign below:
State of North Carolina
County of Wake
I, a Notary Public, do hereby certify that on this
personally appeared before me
day of
day of
who are all signers of the foregoing instrument, and each acknowledges the due execution thereof. IN WITNESS
WHEREOF, 1 have hereunto set my hand and official seal this day of
Notary
My Commission Expires
SEAL
Revised 911912019 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 911912019
Page 5