SW3170101_Application Form_20230503

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://de4. 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 NCA C 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 sire or design of the SCM(s).
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW3170101
2. Current Permit Holder's Company Name/Organization: St. Phillip Catholic Church
3. Signing Official's Name: Father Thomas Kessler
4. Signing Official's Title: Pastor
5. Mailing Address: 525 Camden Drive
City: Statesville State: NC ZIP: 28677
6. Street Address (if different):
City: State: ZIP:
7. Phone: [phone] Email: stphilipapostleCc-Dbeli_south.net
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):
Removal of existing_ classroom building_ and construction, of new classroom building.
Built -upon area (BUA) is- decreasing; however, plans note future allowable QUA such that the future
total BUA equals what was allowed under the original permit (SW3170101).
B. SUBMITTAL REQUIREMENTS
Please mark "Y" to confirm the items are included with this form. Please mark )C" 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).
N/A 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.
NIA 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: Frank G. Miller. PE ^ _�
Consulting Firm: Little Diversified Architectural Consulting
Mailing Address:615 South College Street, Suite 1600
City: Charlotte State: NC Zip: 28202
Phone: [phone] Fax: ( )
Email: frank. miller(oVittleonline.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: I -Fax:
Email: :
D. CERTIFICATION OF PERMITTEE
I, Father Thomas Kessler , the current permittee, certify that I have authorized the
minor modifications listed in Section A and shown in the attached revised plan sheets. I further attest that this
information is accurate and complete to the best of my knowledge.
Signature:
I, QOLXriSSa 'QngnAe-kt —,a Notary Public for the State of 00r4Jn 0pfpl\ n0L, ,
County of lc a ell do hereby certify that �aMrte r :Mamas K PS S 1 e
personally appeared before me this the _ 1 y day of A fjr i 1 , 20—a, and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature �J r
My commission expires V l I `I G© J
Stormwater Permit Form T Minor Modification Page 2 of 2 Oct 6, 2017