NCC192597_Modification Review (LEG RESP CHANGE)_20201217

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/16/2020 2:01:28 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 12/17/2020 7:51:22 AM (Construction COC ADD TO FILE Review- NCC192597)
• The task was assigned to Georgoulias, Bethany. The due date is: December 21, 2020 5:00 PM
12/16/2020 2:01 PM

NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC192597
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Castleberry Trails
Address
605 Wimberly Road, Apex, NC
County
Wake
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
Toll Bros. of North Carolina II, Inc.
Legally Responsible
Perry Verille
Individual
NC Reference No.
NCG01-2019-2597
E&SC Plan ID
18-004
Original NOI
17896
Tracking No.*
Date COC Issued*
11/01/2019
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This field will populate only if COChas already been rescinded.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 * a Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
F Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)

Addional We information if needed (e.g., new Site Contact details can be included here)
Explanation Change out Perry Verille's Contact Info w/the following for Legally Responsible
individual:
Ted Pease
Sr. Vice President, Raleigh Division
Toll Brothers
900 Perimeter Park Drive, Suite B3
Morrisville, NC 27560
Office: [phone]
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 Ibcurrentation (Fevised E&SCApproval, nose -Out Doc, etc.)
Documentation 20201216141004286.pdf 824.18KB
Wst be FDFformat
North Carolina General Statute 143-215.6113 (i) 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 Amide 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).
I� 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
f 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Ted Pease
Title * Sr. Vice President, Raleigh Division
Organization* Toll Bros. of North Carolina 11, Inc.
Date * 12/16/2020
Email Address* [e-mail]
En -ail for confirmation
Telephone Number* 919-321-4800
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.

Additional Email [e-mail]
(Optional) Additional errail for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 12/17/2020
Rescinded Since
Submitted?
Request Date 20201216
Formatted
Review Date 20201217
Formatted