NCC193331_Notice of Termination_20210120

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/20/2021 2:18:55 PM (NOT Submittal)
Approve by Morman, Alaina 1/20/2021 4:46:07 PM (NOT Request Review- NCC193331)
• The task was assigned to Morman, Alaina. The due date is: January 25, 2021 5:00 PM
1/20/2021 2:19 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC193331
Coverage (COC)
Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Cheval Subdivision lot grading (#402182) - Paris
Address
5820 Joli Cheval Lane, Charlotte, NC
County
Mecklenburg
Latitude
35.1550
Longitude
-80.6540
Permittee Listed
Sage Custom Homes, LLC
Legally Responsible
Randy Sage
Individual
NC Reference No.
NCGO1-2019-3331
E&SC Plan ID
Cheval Subdivision lot grading (#402182)
Original NOI
19923
Tracking No.
Date COC Issued
1/3/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Ad d io n a I We inforrration about the basis of this request, if needed.
Explanation Additional NCG01 was requested and
attached.1
Supporting Upload Supporting Dccurrentation if applicable.
Documentation Mast beFDFforrrat

Project Close-out Information:
Final Close-out 1/13/2021
Inspection Approval
Project Close-out NOT release paperwork paris.pdf
Approval NOT Request Form - Construction Stormwater
Documentation
NCG01 o.pdf
NOT release - Paris - 011321.pdf
Mist be Ft7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
1.06MB
44.61 KB
93.16KB
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto a)Ceed ten thousand
dollars ($10,000).
rJ I, as an authorized representative, hereby request rescission of coverage under
the NPDES Stormwater Permit for the subject facility. I am familiar with the
information contained in this request and to the best of my knowledge and
belief such information is true, complete and accurate.
*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 IV, Section B,
Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
rellol4501PI,
Type Name* Angela Sage
Title * Vice -President
Organization* Sage Custom Homes, LLC
Date * 01 /20/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7043632956
NOT Certification NOT release paperwork paris.pdf 1.06MB
Form Mast be FOF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification Bmils
[e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]