NCC200546_MODIFICATION Supporting Documents_20200515

NCG01 legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOQ.
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, Wh Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Certificate of Coverage (COC) Number: NCC200546
Name of Project: Preston Park
Legally Responsible Organizational Entity: Merita a Homes of the Carolinas. LLC
PREVIOUS Legally Responsible Individual: Brett Manery
NEW Legally Responsible Individual: Tad LU ibihl
The following section is to be completed-and-signed-by-the-NE-W Legally Responsible Individual.
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
IXI I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
IN This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date: f
Print Name of Signed: Tad Ltihl r
Title: Vice President of Finance
Mailing Address:13928 Ballant ne Corporate Place Suite 300 Charlotte. NC 28277
Email address: tad.lugibihl(cD_medtagehomes.com
Phone Number: f704) 994-8987 _
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part 1V, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

�u
- Mecklenburg County Soil Erosion and
. y ` Sedimentation Control Ordinance
GA Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Preston Park
2
Address of land -disturbing activity: 460 Marie Way, Pineville, NC 28134
3. Approximate date land -disturbing activity will commence: 4
Month
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5.. Approximate acreage of land to be disturbed or uncovered: 79
6. Total site acreage: 145.29
01 2020
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Meritage Homes of the Carolinas, Inc.
Address: 13925 Ballantyne Corporate Place, Suite 300
Charlotte, NC 28277
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 6719 page 435 Book 16409 page 250
Book 9570 page 326 Book 4978 Page 856
Book 22780 Page 36 Book 29859 Page 259
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Meritage Homes of the Carolinas, Inc.
Address: 13925 Ballantyne Corporate Place, Suite 300
Charlotte, NC 28277
Telephone: [phone]
Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: _
Email Address:
Fax:
3. The above information 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, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
Printed Name
Signature
r
County of
1!Qr]
certify that Q L.
of -
V R in�nCr[_
Title
/r. >--o
Date
a Notary Public of the
State of t 1. r Q , hereby
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand ar4 notarial seal, this j , 7 day of r , 20 J.
Notary Signature: D au
My Commission expires:
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237 Ste_�phanie P Plyler
Phone [phone] Notary Public
Mecklenburg County
M Commission ECxai es a