NCC190290_Modification LOT 694 Review_20210805

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/4/2021 11:35:53 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/5/2021 7:13:08 AM (Construction COC ADD TO FILE Review- NCC190290)
The task was assigned to Georgoulias, Bethany A. The due date is: August 9, 2021 5:00 PM
8/4/2021 11:35 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC190290
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Chapel Ridge - Triple A Homes
Address
163 Birdie Ct, Pittsboro, NC
County
Chatham
Latitude
35.7894
Longitude
-79.2329
Permittee Listed
Triple A Homes
Legally Responsible
Gerry Felton
Individual
NC Reference No.
NCG01-2019-0290
E&SC Plan ID
2019-03668
Original NOI
11059
Tracking No.*
Date COC Issued*
05/16/2019
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This field will populate only if COChas already been rescinded.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 * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
Explanation adding lot 694
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 (%vised I&SC Approval, (lose -Out Doc, etc.)
Documentation CR 694 SoiIErosion Sedimentation Co application
126.54KB
approval.pdf
Mist be FDFfornat
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 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).
� 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Gerry Felton
Title * VP
Organization * Triple A Homes
Date * 08/04/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9498120991
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional errail for conf irrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 08/05/2021
Rescinded Since
Submitted?

Request Date 20210804
Formatted
Review Date 20210805
Formatted