SW6201005_Application Form_20230201

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: http://deg. nc. pov/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 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: Permit No. SW6201005
2. Current Permit Holder's Company Name/Organization: Raeford Development Company, LLC
3. Signing Official's Name: Mubarak Shahbain
4. Signing Official's Title: Manager
5. Mailing Address: 1184 Fayetteville Rd.
City: Raeford State: NC ZIP: 28376
6. Street Address (if different):
City: State: ZIP:
7. Phone: [phone] Email: Jamal(c-)iandkbuilders.com
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):
We would like to revise the proiect area designation and the impervious allocation for the lots.
B. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark `Y' 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).
Y 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 4. If applicable, the appropriate Express review fee.
Stormwater Permit Form 7: Minor Modification Page 1 of 2 July 14, 2017

C. CONTACT INFORMATION
1. The Design Professional who is authorized to provide information on the Applicant's behalf:
Design Professional's Name: C. Scott Brown, PE
Consulting Firm: 4D Site Solutions Inc.
Mailing Address:409 Chicago Drive Ste. 112
City: Fayetteville State: NC Zip: 28306
Phone: [phone] Fax: ( )
Email: sbrown(a)4dsitesolutions.com
2. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: ) Fax: ( )
Email:
D. CERTIFICATION OF PERMITTEE
modifications listed in Section
accurate and gbmplete to thy'
Signature:
the current permittee, certify that I have authorized the minor
nd shown in the attached revised plan sheets. I further attest that this information is
of my knowledge.
I, WculmArm"- Nklow a Notary Public for the State of NrHtN 0AVtUr,0a
County of ;-IOLk do hereby certify that R%AA c YCL L 5hn1h1DCUV1
persgpel appeared before me this the I I-rk day of Noyernbe r 20�, and
�p due execution of the forgoing instrument. Witness my hand and official seal,
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My commission expires hU - ;�0- oi0*aJ
Stormwater Permit Form 7: Minor Modification Page 2 of 2 Oct 6, 2017