NCC201531_Notice of Termination_20210504

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/4/2021 1:10:10 PM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/6/2021 9:52:14 AM (NOT Request Review- NCC201531)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/6/2021 9:43 AM
The task was assigned to Morman, Alaina. The due date is: May 7, 2021 5:00 PM 5/4/2021 1:10 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201531
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Duke's House 2.0
Address
Buckingham Avenue, Fayetteville, NC
County
Cumberland
Latitude
35.0748
Longitude
-78.8789
Permittee Listed
Par 5 Development Group, LLC
Legally Responsible
Jody Bland
Individual
NC Reference No.
NCG01-2020-1531
E&SC Plan ID
CUMBE-2020-125
Original NOI
24359
Tracking No.
Date COC Issued
5/1/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other Project terminated prior to the start of any land disturbing
activities.
Add ional Nbre information about the basis of this request, if needed.
Explanation This project was terminated prior to the start
of any land disturbing activities.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
Anyperson who knowinglymakes any false 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 knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who 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 not to exceed ten thousand
dollars ($10,000).
17 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
Type Name * Jamie S. Encinosa
Title * Vice President
Organization * Par 5 Development Group, LLC
Date * 05/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-944-0881
NOT Certification NCC201531 Signed Notice of Termination.pdf
Form Mast be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Brails
(Optional)
Original Permittee CCd on Notification Brails
Email [e-mail]
49.24KB

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