NCC242612_Contact Update Supporting Docs (LEG RESP CHANGE)_20250313

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).
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 122.221
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

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Cleveland Hill
1. Project Name
Cleveland City or Shelby
2. Location of land-disturbing activity: County ty P
Highway/street Eaves Road Latitude 32.264101 Longitude-81 .530729
3. Approximate date land-disturbing activity will commence:
9/1/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):53
6. Amount of fee enclosed: $ The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
[e-mail]
Name
Mark Henninger E-mail Address
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lennar Carolinas, LLC 704-759-6000
Name Telephone Fax Number
11605 N Community House Rd Suite 400 11605 N Community House Rd Suite 400
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
10. Deed Book No. 1264 Page No.800 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Lennar Carolinas, LLC
Name E-mail Address
11605 N Community House Rd Suite 400 11605 N Community House Rd Suite 400
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
704-759-6000
Telephone Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Corporate Creations Inc.
Name E-mail Address
15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Charlotte, NC 28227
City State Zip City State Zip
Telephone [phone] Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Lennar Carolinas, LLC
Name of Registered Agent E-mail Address
11605 N Community House Rd suite 400 11605 N Community House Rd Suite 400
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
Telephone [phone] Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Mark Henninger Division President
Type or print nam Title or Authority
Signature Date
----------------------------------------------------------------------------------------------------------------- --------------
I, Pejit& eUM im I nS ,, a Notary Public of the County of 1XL6✓rU S
' 7t
State of North Carolina, hereby certify that ' W�' M a a— appeared
personally before me this day and being duly sworn acknowled ed that the above form was
executed by him.
Witness my hand and notarial seal,this 16* day of 20 Q15*
MELISA CUMMINS MAO
NOTARY PUBLIC Notary
Cabarrus County q
NWairarollna I^�vN
My Commission Expires July4,2028 My commission expires