HomeMy WebLinkAboutSW3180501_Permit Information Update Form_20201209Date Received Fee Paid Permit Number
STATE T T
PERMIT INFORMATION UPDATE APPLICATION
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of
1) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation, HOA or POA),
2) changes to the mailing address, phone number or email address of the current permittee,
3) changes to the name of the project; and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
State Stormwater Permit Number: SW3180501
Are you updating
(check all that apply):
If so, please provide the updated information:
❑ Project name
❑ Corporation Name'
® Permit Contact Name2,3
�
Veera Thota
® Permit Contact Title
Director
® Mailing Address3
7013 South Creek Road Charlotte, NC 28277
® Phone number
314-757-2295
® Email address
kasthotstgmail.corn
Provide documentation such as a Name Change / Merger filed with the NCSOS,
Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A_NCAC 0 H .1040(1) ..
If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Veera Thota , the current acting permittee, hereby notify DEMLR that I am making the
changes as listed in Section A above. I further attest that this application for an update to the permit information currently
on file is accurate and complete to the best ;—,
y knowledge.
,r `P
Signature: "i-� V " µITV Date: �I
I, a Notary Public for the State of tiv'� �c"✓
r
r
County of ,.���t2. i do hereby certify that V�-%�i,, �y '�"�
ersonall a before me
p y eared pp this the 07 day of C ::: ;)'1. 20 2p and acknowledge the due
execution of the forgo' instru
ment. _ ument. Witness my hand and official seal,
ZULF11A
(Notary Seal) AZNBE VA
Notary Public
IUt€'Chf nbur. Co., No
ycr��l rth Ceroldns
ir.rrr -
Notary Signature's r:i°'� ..J''
My commission expires ,,9, 'k
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017
DEIVILR USE ONLY
Date Received Fee Paid Permit Number
STATE "rRIB "T"ER:
PIE IT IINIF II I iATII Iq UPDATE API I. IICATIOIN FORM
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of.-
1) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation, HOA or POA),
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project, and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW3180501
Are you updating
(check all that apply)..
If so, please provide the updated information:
❑ Project name
❑ Corporation Name'
® Permit Contact Namez ,3
Veera Thota
® Permit Contact Title
Director
® Mailing Address3
7013 South Creek Road Charlotte INC28277
® Phone number
314-757-2295
® Email address
kasthota gmail.com
Provide documentation such as a Name Change / Merger filed with the NCSOS.
Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with l 55A NCAC 02I-I . I0 0 .
If more than one point of contact or mailing address is being changed, please attach a separate sheet.
I, Veera Thota , the current acting permittee, hereby notify DEMLR that I am making the
changes as listed in Section A above. I further attest that this application for an update to the permit information currently
on file is accurate and complete to the best of my knowledge.
Signature: "y
ate: f 7 `..........
a Notary Public for the State of J �
County of .* C j do hereby certify that
rso If eared before me day of""27��' 20�, and acknowledge the due
p �.y appeared this the
e &MLOPAI Ao d y i51K N ne s my hand and official seal,
Notary Public
( °tale i burg Co., North Carolina
My Commission Expires Feb. 25, 2025
Notary Signature'/? ;��"� t°'��{�
My commission expires 011,
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017