NCC191082_NOT Signed Certification_20201218

Notice a �n lio T icatio "! Form
Print this form, complete, scan and upload to the electronic NOT (Rescission) 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, 6tr Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: 191ag
Name of Project:
Per PAC 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),
Under p-natty of law, I certify that:
�—Zl, 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 infori-nation is true, complete, and
accurate.
Legally Responsible Organizational i ntity: C K .
*Legally Resl,
Title of Leg
Signature:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*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 IL 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.

Property Address:
Jurisdiction:
Job Description:
Property Description
Mecklenburg County
Certificate of Compliance
Land Use and Environmental Services Agency
Code Enforcement Division
Not Intended to Grant Occupancy
248 GREY RD
DAVIDSON
CMR BUILDERS / NEW RES J PLN REV
Parcel Number: 00315202
Lot Number:
Building Permit Information
Permit Number:
Permit Type:
Contractor:
B3575211
Onc/Two Family
C M R BUILDER INN
Permit Issue Date:
'This Certificate of Compliance is issued in conformance with NC GS 153A-363 and Gs 16dA-423'
'By issuing this Certificate of Cam pliance the ❑epartment represents that the scope of work,
desedbed in the above referenced permit only, is complete. As indicated in the GS 153A-363 and
GS 16CA-423, this Certificate of Compliance shall nat be construed to grant authority to occupy [his
building.'
'This is not a Cerfifcate of Q6cuaangy''
'A Certificate of Occupancy designates the occupancy type which may be safety occupied.'
Unit: 248 GREY RD
2019-07-30 00:00:00
BYC� V... w—.
DIRECTOR
2020-08-12 1424:48
DATE OF CERTIFICATION
Wednesday, August 12, 2020 Page 1 of 1