NCC216852_Contact Update Request (Leg Resp Change)_20231205

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead,you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete,scan and upload to the Construction Stormwater Permit MODIFICATION 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, 61h Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number: cc_0 1 ka-11�51S a
Name of Project: \S�� (K A iZ - )
1 \'
Legally Responsible Organizational Entity: t+ 04 CSu��ov LLL
PREVIOUS Legally Responsible Individual: �►-45�,`rl 1a Qa���
NEW Legally Responsible Individual: , 0-11
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E(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).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project,for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit,
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
,Pf If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
{ Part II of the permit are met on the project at all times.
W� I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
1Z This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date: /q os1110�-
pZ[7
Print Name of Signed: o-"' a\C Z&'� DA 5
Title: 'b' t n (� 1
Mailing Address: `7 0C)u �e1\\5 0� nP�tiS� tZ , Sw�c o?�a 1n� I�iCh /I(— a 7CP)6
Street Address: 7 )L)o F—vo� o.� �e�S2 ej . S%-c-i�e- C)Od Y����i�� (�L o1 � GO)�
Email Address: (r n t�j--e,(rD�CtS ea w� [)01 5�Ic e5.. Lo
Phone Number: °I - 3 7 - `{ -7 6
* 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 IV,Section 8, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV, Section B, Item (6)of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Kim Litman <[e-mail]>
Sent: Tuesday, December 5, 2023 1:24 PM
To: Georgoulias, Bethany
Cc: Holloman, Tevye L;Jonathan Massey
Subject: RE: [External] RE: Construction SW Permit Contact Information Update for NCC216852
Attachments: 20231205134326924.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Attached is a scan of the completed document, the original is going in the mail today.
Thank you.
Kim Litman
Office Coordinator
(� Dream Finders Homes
T
DREAM FINDERS COMES a: 7200 Falls Of Neuse Rd, Suite 202, Raleigh, NC 27615
o: 919-374-3473
e: kim.litman(a�dreamfindershomes.com
Official Home Builder of the PGA TOUR w:www.dreamfindershomes.com
00000
From: Georgoulias, Bethany<[e-mail]>
Sent:Tuesday, December 5, 2023 8:26 AM
To: Kim Litman <[e-mail]>;Jonathan Massey
<[e-mail]>; RaleighLandlnvoices<[e-mail]>
Cc: Holloman,Tevye L<[e-mail]>
Subject: RE: [External] RE: Construction SW Permit Contact Information Update for NCC216852
Caution: CAUTION:This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.
Kim,
We can only update legally responsible individual when the attached form has been completed. You can scan and email
a copy to us, but the original signed copy must be mailed in.
Thank you,
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral,and Land Resources
N.C. Department of Environmental Quality
i

919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
From: Kim Litman <[e-mail]>
Sent:Tuesday, December 5, 2023 8:23 AM
To: [e-mail];Jonathan Massey<[e-mail]>;
RaleighLandlnvoices<Raleigh Land [e-mail]>
Cc: Holloman,Tevye L<[e-mail]>; Georgoulias, Bethany<[e-mail]>
Subject: [External] RE: Construction SW Permit Contact Information Update for NCC216852
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Couple more changes needed.
Please update Legally Responsible Individual to:
Jon McReynolds, Division President, 919-291-1090, [e-mail]
Street and mailing address, add Suite number to reflect:
7200 Falls of Neuse Road, Suite 202, Raleigh, NC, 27615-5384
Thank you.
Kim Litman
Office Coordinator
Dream Finders Homes
DREAM FINDERS HOMES H a: 7200 Falls Of Neuse Rd, Suite 202, Raleigh, NC 27615
a o: 919-374-3473
e: kim.litman(a�dreamfindershomes.com
Official HomeBuilder of the FGATOUR w:www.dreamfindershomes.com
00 0 Q
From: [e-mail]<[e-mail]>
Sent: Monday, December 4, 2023 5:01 PM
To: Kim Litman <[e-mail]>;Jonathan Massey
<[e-mail]>; RaleighLandlnvoices<[e-mail]>
Cc:[e-mail]; [e-mail]
Subject: Construction SW Permit Contact Information Update for NCC216852
Caution: CAUTION:This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.
This email is to notify you that contact information has been updated for South Lakes SF-8 AR-1, under COC No.
NCC216852. You can review the information in the permit folder in our Laserfiche Repository.
2

The following contact information is now associated with this permit record. If anything is in error, please contact
Bethany Georgoulias at [e-mail] gov.
Legally Responsible Individual
Justin Heaton
[e-mail]
732-644-0555
(Mailing Address) 7200 Falls of Neuse Road, , Raleigh, NC, 27615-5384, US
(Street Address) 7200 Falls of Neuse Road, , Raleigh, NC, 27615-5384, US
Site Contact
Jonathan Massey
(Organization) Dream Finders Homes
[e-mail]
919-215-6304
(Mailing Address) 7200 Falls of Neuse Road, , Raleigh, NC, 27615-5384, US
Billing Contact(if available)
[e-mail]
919-215-6304
This change was requested by:Jonathan Massey, Land Development Manager, via email on 12/4/2024
Be sure to add [e-mail] to your contacts to avoid future e-mails about this application from
going into Spam filters.
The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
This email was automatically generated by Laserfiche. Please do not respond to this email address, as responses are not
monitored.
Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and
others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or
taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast, a leader in email
security and cyber resilience. Mimecast integrates email defenses with brand protection, security awareness training, web security,
compliance and other essential capabilities. Mimecast helps protect large and small organizations from malicious activity, human
error and technology failure; and to lead the movement toward building a more resilient world. To find out more, visit our website.
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Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized
state official.
Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and
others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or
taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast, a leader in email
security and cyber resilience. Mimecast integrates email defenses with brand protection, security awareness training, web security,
compliance and other essential capabilities. Mimecast helps protect large and small organizations from malicious activity, human
error and technology failure; and to lead the movement toward building a more resilient world. To find out more, visit our website.
4