SW6220101_Application Form (info Update)_20230831

DEMLR USE ONLY
Date Received Fee Paid Permit Number
STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION 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: SW6220101
Are you updating If so, please provide the updated information:
(check all that apply):
▪ Project name Creekside Oaks South
❑ Corporation Name'
[' Permit Contact Name2,3
❑ Permit Contact Title
❑ Mailing Address3
❑ Phone number
❑ Email address
Provide documentation such as a Name Change/Merger filed with the NCSOS.
2 Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .1040(1).
3 If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Watson Caviness , the current 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: Date:
, a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this the day of , 20 , and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature
My commission expires
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017