NCC230835_Contact Update Supporting Doc (LEG RESP CHANGE)_20250314

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, 6tn 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: See attachment for list Of COCs
Name of Project: See attachment
Legally Responsible Organizational Entity: Lennar Carolinas, LLC
PREVIOUS Legally Responsible Individual: N/A Address Change
NEW Legally Responsible Individual: N/A Address Change
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).
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NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that(check all boxes to indicate your agreement):
LJ 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.
L� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
!� 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 fI of the permit are met on the project at all times.
i 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.
Cv'/ This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date:
Print Name of Signed:
Title: `n
MailingAddress: \\CoOS
Street Address: <,'QV-)np CkS C'ppv-- NL
Email Address: M
Phone Number: b O
* IMPORTANT NOTE: This farm 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 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCG010000 permit.
Page 2 of 2

Len narAddress Change COC'sAffected
Bakers Creek-NCC233278
Bell Farm-NCC213868
Brightwater Phase 1-NCC210549
Brightwater Phase 2-NCC223682
Cameron Commons-NCC211148
Cleveland Hill-NCC242612
Creekside Cottages-NCC230835
Crowders Creek-NCC243492
Falls Cove Phase 3-4-NCC220440
Gambill Forest-NCC215272
Green briar-NCC215442
Legacy Ridge-NCC231038
Red hawk Phase 1-NCC231021
Redhawk Phase 2-NCC242144
Retreat at Cameron Commons-NCC223889
Shannon Woods Phase 1-NCC240709
Shannon Woods Phase 2-4-NCC240496
Sullivan Farm-NCC220224
Summerlyn Village-NCC230819
The Vines-NCC240732
The Villages of Waxhaw-NCC240244
Winecoff Village-NCC243628