20041238 Ver 4_Certification of Completion_20141215

Burdette, Jennifer a
From:
Burdette, Jennifer a
Sent:
Monday, December 15, 2014 11:53 AM
To:
walton, todd; Steenhuis, Joanne
Subject:
RE: certification form - NCSPA
Jennifer Burclette
y
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third parties unless the content is exempt by statute or other regulation. *
From: walton, todd
Sent: Monday, December 15, 2014 11:33 AM
To: Burdette, Jennifer a; Steenhuis, Joanne
Cc: walton, todd
Subject: certification form - NCSPA
Do you need a hard copied mailed to you all?
Todd C. Walton
Environmental Supervisor
NC State Ports Authority
910 - 251 -5678
Email to and from this address is subject to North Carolina public records law and may be disclosed to authorized third
parties.
1

Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return this certificate to the DWR
401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC, 27699 -1650. This form may be
returned to DWR by the applicant, the applicant's authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
Applicant's Certification
I, Paul 1 Cozza , hereby state that, to the st of my abilities, due care and diligence was used in the
observation of the constructi u h at the construction was observed to be built within substantial
compliance and intent of e ter Quality ertification and Buffer Rules, the approved plans and
specifications, and of ting materials.
Signature:
Agent's Certification
Date: / Z - /S—•
I, hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be
built within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature:
Date:
If this project was designed by a Certified Professional
I, as a duly registered Professional (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to
observe (periodically, weekly, full time) the construction of the project, for the Permitee hereby state that,
to the best of my abilities, due care and diligence was used in the observation of the construction such
that the construction was observed to be built within substantial compliance and intent of the 401 Water
Quality Certification and Buffer Rules, the approved plans and specifications, and other supporting
materials.
Signature:
401 & Buffer Permitting Unit
1650 Mail Service Center, Raleigh, North Carolina 27699 -1650
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www wwateraualitv.oro
An Equal Opportunity 1 Affirmative Action Employer
Date: