NCC192612_Modification Review (LEG RESP CHANGE)_20200422

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/19/2020 1:04:47 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/22/2020 9:32:58 AM (Construction COC ADD TO FILE Review- NCC192612)
p Verified with applicant on 4120 via email that SDH Charlotte LLC is still the correct legal entity (no
change); this modification is simply a notification that Ron Willing is no longer the legally responsible
individual.
• The task was assigned to Georgoulias, Bethany. The due date is: April 23, 2020 5:00 PM
4/19/2020 1:04 PM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC192612
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Dogwood Forest
Address
1904 John Moore Road, Monroe, NC
County
Union
Latitude
35.0230
Longitude
-80.5900
Permittee Listed
SDH Charlotte LLC
Legally Responsible
Ron Willing
Individual
NC Reference No.
NCG01-2019-2612
E&SC Plan ID
20-00200402
Original NOI
17935
Tracking No.*
Date COC Issued*
11/01/2019
Prior Rescission
This field will populate only ff ODChas already been rescinded.
Date
Modification Information:
Reason for f Closed -Out Lots/Outparcels in E&SC Plan
Modification* r Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre iriforrration if necessary
Explanation Change in "Legally Responsible Person" from Ron Willing to Emily Powell, VP of
Land Acquisition
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).

Supporting Upload Supporting Documentation (%vised ESCApproval, (lose -Out Doc, etc.)
Documentation NOI Change Contact Ron Willing.pdf 50.06KB
Mast be FDFfon-rat
North Carolina General Statute 143-215.66 (1) provides that:
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 knowingly renders
inaccurate any recording or monitoring device 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 exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, hereby request modification to coverage
under the NPDES Stormwater Permit for the subject project site. 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 1A
Type Name* Emily Powell
Title * VP of Land Acquisition
Organization* Smith Douglas Homes
Date * 04/19/2020
Email Address* [e-mail]
57ail for Confirmation
Telephone Number* 704-575-9310
Contact Number if we need to reach you
Review Date 04/22/2020
Request Date 20200419
Formatted
Review Date 20200422
Formatted