NCC192153_Modification Review_20200110

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/7/2020 12:15:08 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 1/10/2020 1:33:33 PM (Construction COC ADD TO FILE Review- NCC192153)
p Applicant uploaded plan sheets only with this modification request. Reviewer requested approval
documentation like the one from the City submitted with the original application and received that via e-mail
on 1/1012020. That additional correspondence will be included with the final permit and mod records.
• The task was assigned to Georgoulias, Bethany. The due date is: January 10, 2020 5:00 PM
1 /7/2020 12:15 PM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC192153
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Carros Property
Address
925 Polo Road, Winston-Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Goodwood Misadventures LLC
Legally Responsible
James Carros
Individual
NC Reference No.
NCG01-2019-2153
E&SC Plan ID
EN1900133
Original NOI
16587
Tracking No.*
Date COC Issued*
10/02/2019
Prior Rescission
This field will populate only ff OOChas already been rescinded.
Date
Modification Information:
Reason for f Closed -Out Lots/Outparcels in E&SC Plan
Modification* r Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre infornation if necessary
Explanation Additional area of disturbance, newtotal disturbed area 3.3 acres.
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload applicable
sheets).

Supporting Upload Supporting Documentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation C1.1 Demo & Ph1 EC 12-19-19.pdf 1.39MB
C6.2 EC Details 12-19-19.pdf 1.41 MB
Wst be FDFformat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, hereby request modification to coverage
under the NPDES Stormwater Permit for the subject project site. I am familiar
with the information contained in this request and to the best of my knowledge
and belief such information is true, complete and accurate.
'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 B,
Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* James Carros
Title * Owner
Organization* Goodwood Misadventures, LLC
Date * 01 /07/2020
Email Address* [e-mail]
Errail for Confirrration
Telephone Number* 3367491615
Contact Number if we need to reach you
Date Formatted 20200107