SW3180501_Application_20201110

DEMLR USE ONLY
Date Received Fee Paid Permit Number
STORMWATER PERMITTING FORM 7:
MINOR MODIFICATION
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: httn://dea.nc.gov/contacbreaional-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 02H .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).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW3180501
2. Current Permit Holder's Company Name/Organization: Shirdl Sal Temple
3. Signing Official's Name: Veera Thota
4. Signing Official's Title
5. Mailing Address:
City: Charlotte
Director
Shirdi Sai Temple, 7013 South Creek Road
State: NC ZIP: 28277
6. Street Address (if different):
City: State: ZIP:
7. Phone:( 314)757-2295 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):
Site was modified, caused a reduction in BUA.
ION y 41
NOV 10 2020
B. SUBMITTAL REQUIREMENTS DENR-LAND QUALITY
Please mark "Y" to confirm the items are included with this form. Please mark X" if previoc T� 0, AWWR§.R?5PITT I NG
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).
N/A 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 July 14.. 2017

C. CONTACT INFORMATION
The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: Jeffery C. Orsborn
Consulting Firm: Orsborn Engineering Group
Mailing Address: 605 Lexington Avenue, Suite 301
city: Charlotte State: NC zip: 28203
Phone: ( 7044749-1432 Fax:
Email:: [e-mail]
[OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title: Jason Banks, El
Organization: Orsborn Engineering Group
Mailing Address: 605 Lexington Avenue, Suite 301
city: Charlotte State: NC zip: 28203
Phone: ( 980-227-1432 1 Fax: ( 1
Email:: [e-mail]
D. CERTIFICATION O�—F� PI�ERMITTEE
I, \1 EF R.1 —/ ty 0Tf1 , 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: V 2l 4e,, s k Date: D 2
I, D ott ot lGS "D , a Notary Public for the State of NC
County of u doh reby certify that 0
personally appeared before me tHs the 2'6day of , 20 210and
ack pAJ%4gQ he due execution of the forgoing instrument. Witness my hand and official seal,
DIR
1l�`. AUB00 ..2a�
My corS'1?111%1'on expires L
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017

DEMLR USE ONLY
Date Received Fee Paid Permit Number
STORMWATER PERMITTING FORM 7:
MINOR MODIFICATION
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: htttp://deg.nc.00v/contact/regional-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 NCA C 02H .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).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW3180501
2. Current Permit Holder's Company Name/Organization
3. Signing Official's Name: Veera Thota
4. Signing Official's Title
Director
Shirdi Sai Temple
5. Mailing Address: Shirdi Sai Temple, 7013 South Creek Road
City: Charlotte State: NC zip: 28277
6. Street Address (if different):
City: State: ZIP:
7. Phone:( 314)757-2295 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):
Site was modified, caused a reduction 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).
N/A 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 July 14, 2017

C. CONTACT INFORMATION
The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: Jeffery C. Orsborn
Consulting Firm: Orsborn Engineering Group
Mailing Address: 605 Lexington Avenue, Suite 301
city: Charlotte State: NC zip: 28203
Phone: ( 704474A-143Fax: ( )
Email:: [e-mail]
[OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title: Jason Banks, El
Organization: Orsborn Engineering Group
Mailing Address: 605 Lexington Avenue, Suite 301
city: Charlotte State: NC zip: 28203
Phone: ( 80- 7-143 ) Fax: ( )
Email:: [e-mail]
D. CERTIFICATION OF PERMITTEE
I, j1 FE&,q SMD & , 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: (4 120 1 2A
I, pOtugkas T>-. S , a Notary Public for the State of 1"
County of LGk k1,\ oUY'J do he by certify thatyeCf 0. O 4-
personally appeared before me this the day of QG+Qbe—Y . 20 2Z and
ar•,014 MMI VS the due execution of the forgoing instrument. Witness my hand and official seal,
/ ,,
O;> (�,�� ►ail ; ;
z
,L UBL
�III44111HM - �1./�+9 D
My commission expires 2-1
VJ `7 ri/)—
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017