NCC213804_Modification Review (LOT A1)_20211011

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/8/2021 10:19:09 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 10/11/2021 7:47:19 AM (Construction COC ADD TO FILE Review -
NCC213804)
• The task was assigned to Georgoulias, Bethany A. The due date is: October 13, 2021 5:00 PM
10/8/2021 10:19 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC213804
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Dairymont
Address
Dairymont Dr., Pittsboro, NC
County
Chatham
Latitude
35.7390
Longitude
-79.2960
Permittee Listed
Baywood Builders, Inc.
Legally Responsible
Matt McKenzie
Individual
NC Reference No.
NCG25-2021-3804
E&SC Plan ID
WP-21-229
Original NOI
57141
Tracking No.*
Date COC Issued*
06/25/2021
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This field will populate only if CCChas already been rescinded.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 * 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
f Multiple Reasons (List)
Addional IVbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nuabers.
Explanation
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 Dairymont Lot Al ESC LOA.pdf 128.7KB
Dairymont Lot Al COC.pdf 36.69KB
Wst be FDFfornat
North Carolina General Statute 143-215.6B (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 Article; 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Matt McKenzie
Title * President
Organization* Baywood Builders, Inc.
Date * 10/08/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 919-618-3702
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional errailfor confirrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 10/11/2021
Rescinded Since
Submitted?

Request Date 20211008
Formatted
Review Date 20211011
Formatted