NCC233149_FRO Submitted_20231020

DocuSign Envelope ID:28BE7286-6C8D-4C52-BD03-F85AA8D6AB49
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM pE
SEDIMENTATION POLLUTION CONTROL ACT ( . 1873 .
WATER RESOURCES 1111
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105-B Upchurch Street O � 2
Town of Apex, North Carolina 27502 T Cs"'h'CAT-
Contact: James Misciagno
.0. 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: Prestwick
Location of Land-Disturbing Activity:Morris Acres Road between Jenks Road and US Hwy.64
Approximate Date Land-Disturbing Activity will Commence:
Acreage of Land to be Disturbed: 15 00
Latitude: 35752491 Longitude: -78.889718
Land Owner(s) of Record (use blank page to list additional owners):
Name: Edith Morris Name:
Current Mailing Address: Current Mailing Address
7208 Morris Acres Road
City,State,Zip:Apex, NC 27502 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:Pulte Home Company,LLC
Telephone:[phone] E-mail:[e-mail]
Current Mailing Address: Street Address (if different from mailing address)
1225 Crescent Green Drive,Cary,NC 27518
City, State,Zip:Cary, NC 27511 City,State,Zip
Revised 3/27/2020 Page 1

DocuSign Envelope ID:28BE7286-6C8D-4C52-BD03-F85AA8D6AB49
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:Chris Raughley Date: I Z/VI/2,2.
Title or Authority: V P `..av-, s P,c,,i j,k,0‘.,Y1ncAnt
Signature: c_AA.,,, c? L.
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I, ,�)tar,,u., C. ,l�e,r�i.«e a Notary Public of the County of W A-�= ,State
of North Carolina hereby certify that C1\4--', 5 Kckv- -, e`l personally appeared before me this
day andr� under oath acknowledged that the above form was executed by him/her. Witness my hand and seal this
e29 day of lle-c.e r.-,b e< , (9 0 D, , . `�.�_`aKOON till
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Financial responsibility encompasses personal liability by the person signing this disclosure fonSeiDd artne in"
partnership or if an officer or director of a corporation which is either:(a)dissolved lawfully under North' Irl s �$t't's:
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(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 3/27/2020 Page 2