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HomeMy WebLinkAboutNCC240030_FRO Submitted_20240108 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Grp P SEDIMENTATION POLLUTION CONTROL ACT . f« . WATER RESOURCES I f ".�.� 105-B Upchurch Street Iti z I fif Town of Apex, North Carolina 27502 Contact: James Misciagna Phone: (919)372-7470 E-Mail:james.rnisc►agno@apexnc.orq 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:THALES ACADEMY APEX K8 Location of Land-Disturbing Activity:1300&1250 N.SALEM ST.APEX,NC Approximate Date Land-Disturbing Activity will Commence:1/15/2024 Acreage of Land to be Disturbed:2.04 Latitude: N:725,537.11 Longitude: E 2,044,427.03 Land Owner(s)of Record(use blank page to list additional owners): Name:THALES ACADEMY Name: Current Mailing Address: Current Mailing Address 4641 PARAGON PARK ROAD City,State,Zip:RALEIGH,NC 27616 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:THALES ACADEMY Telephone:919.605.3860 E-mail:ROBERTCORLETT@CAPTIVEAIRE.COM Current Mailing Address: Street Address(if different from mailing address) 4641 PARAGON PARK ROAD City,State,Zip:RALEIGH,NC 27616 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. Tl1e 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. N/A Name: N/A Telephone: Current Mailing Address: Street Address(if different from mailing address) N/A N/A N/A N/A N/A N/A 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. ROBERT L. LUDDY 12/11/2023 Name: Date: CH RMAN Title or Authori • Signature: �j I, /i /� NA)/Se-- a Notary Public of the County of (J/(,k...0 r State of North Carolina hereby certify that-10624 (. L i personally appeared ,irm,his day and under oath acknowledged that the above form was e�ckcute yhim/her. Witness my It �`rM.st�q*p/s/0, 4.9 l day of , ?o9-3 . 0Y/dCild PUBLIC Notary My Commission Expires COU Financial responsibility encompasses personal liability by the person signing this disclosure form•,/i'fjnip r 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: Alexander Design Build Telephone:(919)324-9261 Telephone: Email: Email: kent@alexanderdesignbUild.com Current Mailing Address: Current Mailing Address 140 Durham Street City,State,Zip:Clayton,NC 27520 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:D.Kent Alexander Date: 0/7-23 Title or Author" :President Signature: .� 1, .r// 73C//( 2s a Notary Public of the County of ,State of North Carolina hereby certify that ,I /1/ atikadet, personally appeared before me this day and under oath ackno edged that the above form was executed by him/her. Witness my hand and seal this // d y of ,�.( l be , 020a,3 . Q.atzt_ 6-2Iejoi , -0/ate 7 SEAL ,,op��nrrrrn„Ae Not ry My Commission Expires o�•ll`` lllE P/14,,,,=„ " OT,q� " 0 FO ; 4 ; - -Z �aLIG 'V ,,,,,,,,,NCO .) ,„,, 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): THALES ACADEMY The names and residences and mailing addresses of all the owners of the business are(Insert name and address of each owner): ROBERT L.LUDDY-ADDRESS:4641 PARAGON PARK ROAD, RALEIGH, NC 27616 IN WITNESS WHEREOF,this certificate is signed by each of the owners of said business,this day of Owner's from a n below: State of North Carolina County of Wake I, }'t LJCL-4.,v S-- t a Notary Public,do hereby certify that on this ( /'IN-- day of tP ` , aa)-- 3 ,personally appeared before me - 0 L + C WO who are all signers of the foregoing instrument,and each acknowledges the due execution thereof. IN WITNESS WHEREOF,I have hereunto set y hand and official seal this I ft day of 0 et. f,6I -B?-3 , ,t,. ..2, `� \,`°� '`'P���SEAL •J�s,- Notary My Commission Expires �' NOTARY = PUBLIC Revised 9/19/2019 ,ij', �a�` 4 I Name of Corporation:THALES ACADEMY Name of registered agent,street address,mailing address of registered office in Wake County: Name:ROBERT CORLETT Street Address:4641 PARAGON PARK ROAD City,State,Zip:RALEIGH,NC 27616 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: ROBERT L. LUDDY-CHAIRMAN Street Address: Street Address: City,State,Zip: City,State,Zip: RALEIGH, NC 27616 Name and Title: Name and Title: WILLIAM FRANCIS-CFO Street Address: Street Address: 4641 PARAGON PARK ROAD City,State,Zip: City,State,Zip: RALEIGH, NC 27616 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