NCC191787_Modification Review CONTACT CHANGES_20210909

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/7/2021 10:00:51 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 9/9/2021 8:11:45 AM (Construction COC ADD TO FILE Review- NCC191787)
* Contact changes made on 91912021.
The task was assigned to Georgoulias, Bethany A. The due date is: September 10, 2021 5:00 PM
9/7/2021 10:00 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC191787
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Padgettown Rd Subdivision
Address
542 Padgettown Rd, Town of Black Mountain, NC
County
Buncombe
Latitude
35.6278
Longitude
-82.3107
Permittee Listed
Builders Partner
Legally Responsible
Dan Hobbs
Individual
NC Reference No.
NCG01-2019-1787
E&SC Plan ID
ER02019-00023
Original NOI
15704
Tracking No.*
Date COC Issued*
09/11/2019
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This field will populate only if COChas already been rescinded.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 MDre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation New site contact individual has changed.
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 IRSCApproval, (lose -Out Doc, etc.)
Documentation BuildersPartner Stormvvater Permit Change Sept
2.23MB
2021.pdf
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 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
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
Type Name* James Langford
Title * Vice President of Construction
Organization* Builders Partner
Date * 09/07/2021
Email Address* [e-mail]
En -ail for confirmation
Telephone Number* 8286911657
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 email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 09/09/2021
Rescinded Since
Submitted?

Request Date 20210907
Formatted
Review Date 20210909
Formatted