SWA000022__03 As-Built Permittee Certification Checklist - Signed_20201001

Project Name u t.QW Permit # SW8 SWA0000
AS -BUILT PERMITTEE CERTIFICATION
I hereby state that I am the current permittee for the project named above, and I certify by my signature below,
that the project meets the below listed Final Submittal Requirements found in 15a NCAC 02H.1042(4) and the
terms, conditions and provisions listed in the permit documents, plans and specifications on file with or provided
to the Division.
❑ Check here if this is a partial certification. Section/phase/SCM # SwA0000ZZ
[Check here if this is part of a Fast -Track As -Built Package Submittal :a=
44(3).
Printed Name Signature
1, a Notary Public in the State of N c)A-�'
County of _H- e_&A eaAr-i—t' do hereby certify that
personally appeared before me this ^'� l day of ; ��. 20-a C)
t
and acknowledge the due execution of this as -built certification. (SEAL) 11110
Witness my hand and official seal .``�'tiEl.IA �,►���,�
L ZZ N
My commission expires _ - ' x PUB4 Y
�'- fir•- -� - -�.
Permittee's Certification 15A NCAC 02H .1042(4)
►►► 1j 11 1%�r
DEED RESTRICTIONS / BUA RECORDS
Completed /
N/A
Provided
I . The deed restrictions and protective covenants have been recorded and
Y or N
contain the necessary language to ensure that the project is maintained
consistent with the stormwater regulations and with the permit conditions.
2. A copy of the recorded deed restrictions and protective covenants has been
to the Division.
Y or N
N/A
provided
3. Records which track the BUA on each lot are being kept. (See Note 1)
Y or N
N/A
MAINTENANCE ACCESS
1. The SCMs are accessible for inspection, maintenance and repair.
2. The access is a minimum of 10-feet wide.
3. The access extends to the nearest public right-of-way.
Completed / N/A
Provided
Y rN
IN
Y)wN
NCDEQ 2/9/2018

Project Name
Permit # SW8
EASEMENTS Completed /
Provided
1. The SCMs and the components of the runoff collection / conveyance system�t N
are located in recorded drainage easements.
2. A copy of the recorded plat(s) is provided. Y ar N
SINGLE-FAMILY RESIDENTIAL LOTS Completed /
Plats for residential lots that have an SCM include the following: Provided
1. The specific location of the SCM on the lot. Y ote
2. A typical detail for the SCM. Y vl
3. A note that the SCM is required to meet stormwater regulations and that the
lot owner is subject to enforcement action as set forth in NCGS 143 Article Y of-0
? 1 if the SCM is removed, relocated or altered without orior annroval,
OPERATION AND MAINTENANCE AGREEMENT Completed /
Provided
1. The O&M Agreement is referenced on the final recorded plat. Y 00
2. The O&M Agreement is recorded with the Register of Deeds and appears in or N
the chain of title.
OPERATION AND MAINTENANCE PLAN Completed /
Provided
1. Maintenance records are being kept in a known, set location for each SCM �jor N
and are available for review. ��JJ
DESIGNER'S CERTIFICATION FORM Completed /
Provided
1. A completed designer's certification form has been provided to the 2Y }or N
Division. l
Provide an explanation below for every requirement that was not met, and for every item marked "NIA."
Attach additional pages as needed.
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NCDEQ 2/9/2018