NCC204093_Notice of Termination_20221117

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/17/2022 3:51:10 PM (NOT Submittal)
Approve by Clark, Paul B 11/18/2022 5:09:44 PM (NOT Request Review - NCC204093)
• The task was assigned to Clark, Paul B by round robin distribution 11/17/2022 3:51 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: November 22, 2022 5:00
PM 11/17/2022 3:51 PM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC204093
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A PAID OPEN
May be blank if N/A May be blank if N/A
This permittee has an OPEN fee. If this NOT request is acceptable, you will have the option to waive that fee, but that is
only available AFTER the Notice of Termination (NOT) has been approved (when the permit status becomes INACTIVE).
If it is appropriate to waive the OPEN fee, it may help to assign that annual fee task to yourself immediately following this
approval so you remember to resolve the outstanding fee.
Information associated with this permit:
Project Name Lot Clearing Plan for Lots 80 - 97 at Avery Pond S/D, Phase III C
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if issuance.
applicable) No longer visible on the initial form (data not captured from initial application)
Address 39, 63, 85, 105, 121, 137, 153, 169, 175, 176, 170, 152, 136, 118, 102, 84, 60, and
36 Old Head Way, Hectors Creek, NC
County Harnett
Latitude 35.4951
Longitude-78.8173
Permittee Listed LGI Homes - NC, LLC
Legally Responsible Keith Sears
Individual
NC Reference No. NCG01-2020-4093
E&SC Plan ID HARNE-200-058 - 075
Original NOI Tracking 31486
No.
Date COC Issued 11/6/2020
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:

Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Erosion Control Plan 6/9/2020
Close-out Date
Erosion Control Plan Lot 80.pdf 165.51 KB
Close-out Lot 81.pdf 165.45KB
Documentation
Lot 82.pdf 165.54KB
Lot 83.pdf 165.62KB
Lot 84.pdf 165.58KB
Lot 85.pdf
165.59KB
Lot 86.pdf
165.35KB
Lot 87.pdf
165.4KB
Lot 88.pdf
165.41 KB
Lot 89.pdf
165.4KB
Lot 90.pdf
165.41 KB
Lot 91.pdf
165.45KB
Lot 92.pdf
165.24KB
Lot 93.pdf
165.59KB
Lot 94.pdf
165.59KB
Lot 95.pdf
165.54KB
Lot 96.pdf
165.15KB
Lot 97.pdf
165.53KB
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
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; or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this 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 guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.

Signature
Type Name*
Keith Sears
Title*
Regional Construction Manager
Organization*
LGI Homes - NC, LLC
Date *
11 /17/2022
Email for
[e-mail]
Confirmation*
Contact Telephone* 9197953922
NOT Certification NOT NCC204093.pdf 111.75KB
Form Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email
CCd on Notification Emails
(Optional)
Original Permittee
CCd on Notification Emails
Email
[e-mail]
Original Site Contact
CCd on Notificaiton Emails
Email
[e-mail]