NCC193004_Modification Review_20201210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 2:52:53 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 12/10/2020 7:46:46 AM (Construction COC ADD TO FILE Review- NCC193004)
* We currently do not have a way to update the address for the COC record, but the record about the
address change will be added to the permit file in the repository.
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 2:52 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC193004
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Providence Square Renovation
Address 5660 International Drive, Charlotte, NC
County Mecklenburg
Latitude 35.0000
Longitude-81.0000
Permittee Listed Golden Triangle #5 - Providence Square, LLC.
Legally Responsible Daniel Levine
Individual
NC Reference No. NCG01-2019-3004
E&SC Plan ID LDGP-2019-00250
Original NOI 19004
Tracking No.*
Date COC Issued* 12/31/2019
Prior Rescission This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Nbre information if needed (e.g., new Site Contact details can be included here)
Explanation The address was changed to 705 International Dr. to facilitate Mecklenburg
County's computer enhanced 911 emergency system (see attached July 29, 2020
letter from Mecklenburg County Geospatial Information Services). We understand
the post office confirmed this.
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).

For changes to the legally responsible individual, you must upload this form.
Supporting upload Supporting Documentation (Revised ERSC Approval, (lose -Out Doc, etc.)
Documentation Prov Square address change notification.pdf 53.43KB
Mast be PDFfon-rat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto exceed ten thousand
dollars ($10,000).
rJ I 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.
Specify if you are:* r The Legally Responsible Individual
r Authorized Responsible Person*
*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
Err zg�'J4E SZZ
Type Name* Daniel Levine
Title * Manager
Organization * Golden Triangle #5 - Providence Square, LLC
Date * 12/09/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 7046883304
Contact nunter if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 12/10/2020
Rescinded Since
Submitted?

Request Date 20201209
Formatted
Review Date 20201210
Formatted