NCC210084_Modification Review_20210412

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/12/2021 3:22:03 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/12/2021 4:31:26 PM (Construction COC ADD TO FILE Review- NCC210084)
* Different organization is listed under signature, but same legally responsible individual for permittee (A.
Sydes Construction, Inc.)
• The task was assigned to Georgoulias, Bethany. The due date is: April 15, 2021 5:00 PM
4/12/2021 3:22 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC210084
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Bennett Place V, Somerset Place V, and Roanoke Bay IV
Address Wood House Drive, Jacksonville, NC
County Onslow
Latitude 34.8697
Longitude-77.4842
Permittee Listed A. Sydes Construction, Inc.
Legally Responsible Anthony Sydes
Individual
NC Reference No. NCG01-2021-0084
E&SC Plan ID
Original NOI
Tracking No.
ONSLO-2021-029
40517
Date COC Issued* 01/12/2021
Prior Rescission This field will populate only if CCChas already been rescinded.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 Ivbre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation E&SC Plan was modified to show design for the first phase of the subdivision.
Previously, this was only showing clearing.
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 Dxurrentation (Pevised E&SCApproval, nose -Out Doc, etc.)
Documentation ONSLO-2021-029 Approval Revised 4-9-2021-1.pdf 234.94KB
Mist be FDFfornat
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 Artide; 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).
� 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* Anthony W. Sydes
Title * President
Organization* Clearly Development, Inc.
Date * 04/12/2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 9104556956
Contact nunber ff we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confirnation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 04/12/2021
Rescinded Since
Submitted?

Request Date 20210412
Formatted
Review Date 20210412
Formatted