SW6200201_Application Form_20230622

DEMLR USE ONLY
Date Received Fee Paid Permit Number
'I •'
1 s
M Q I TIC% K*
Standard Permitting Program — No Fee for Minor Modification
Express Permitting Program — See Express Fee Schedule
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: htt .rIlde .tac. ov/contac 're iqnal-offices.
This form is to only to be used by the current permittee to notify the Division of a minor
modification. Pursuant to Rule 15A NCAC 02 ,1002, a minor modification is a change to the project that.
1) does not increase the net built -upon area; and/or
2) does not change the size or design of the SCM(s).
1. State Stormwater Permit Number: SW6200201
2. Current Permit Holder's Company Name/Organization: Greenfield = Serenity., LLC
3. Signing Official's Name: Yang Song
4, Signing Official's Title: Manager
5, Mailing Address: 8601 Six Forks Road Suite 270
City: Raleigh State: NC ZIP: 27609
6. Street Address (if different): : Same as Mailing]
City: - State: - ZIP:
7. Phone: [phone] Email: [e-mail]
8. Describe the minor modifications that you are requesting, including any revised BUA allocations (attach
additional pages or supporting tables similar to Section IV.10 of the original application, if needed):
Addina one additional lot and re -allocating BUA throughout lots in Phase 213. No increase in BUA.
B. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark W" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. Two hard copies (with original signatures) and one electronic copy of this completed form.
Y 2. Two hard copies and one electronic copy of the revised plan sheets (must be a revision of the
originally approved plan sheets).
Y 3. If there is reallocation of lot BUA, a copy of the revised recorded deed restrictions and protective
covenants OR the proposed recorded deed restrictions and protective covenants documenting
the changes and a signed agreement to provide the final recorded document.
N/A 4. If applicable, the appropriate Express review fee.
Stormwater Permit Form 7: Minor Modification Page 1 of 2 Oct 6, 2017

C. CONTACT INFORMATION
1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: Mike Zaccardo PE
Consulting Firm: Timmons Group
Mailing Address:5410 Trinity Road, Suite 102
City:Ralei h
Phone: [phone]
Email:: mike.zaccardo timmons,com
State: NC Zip: 27607
Fax: [phone]
2. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization:
Mailing Address:
City: State:
Phone: ( )
Email:
Zip:
1, yAVCr So/ cz the current permittee, certify that I have authorized the minor modifications listed
in Section A and shown in the attached revised plan sheets. I further attest that this information is accurate and
complete to the best of my knowledge.
Signature:
Date: 03/3 I / 2-02-3
1, , a Notary Public for the State of ,- c.R�z nak
County of weg]� do hereby certify that IAQ(�
personally appeared before me this the .3►r day of , 20_a3_, and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
KRISTLE H. OSTEEN
(Notary Seal) NOTARY PUBLIC
WAKE COUNTY, N.C.
Notary Signature , ,_ �4 1 .
My commission expires Jy-*j"e ► rl i �1
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017