20120377 Ver 2_Certification of Completion_20171222

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 12/22/2017 4:21:14 PM (Start)
BIMSUpdated by Carpenter,Kristi 1/2/2018 2:53:44 PM (DOT Project)
• The task was assigned to Carpenter,Kristi 12/22/2017 4:21 PM

Staff Review
DWR Project #: 20120377
Version: 2
Upon completion of all v�rork approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to submit it to the DWR 401 & Buffer Permitting Branch. This form
may be returned to DWR by the applicant, the applicanYs authorized agent, or the project engineer. It is not necessary
to send certificates from all of these.
Is this a Public Transportation Project? �I7 Yes
�� No
DWR Project #: Version:
20120377 2
County: Wake -
401 Water Quality Certification Issued Date:
9/ 13/2012
Applicant: NCDOT
Project Name: Clegg Passing Siding and Hopson f
Suppleme ntal AttaChments: C7ickthe upload button or drag and drop files here to attach docurrent
F�F only
Who will be submitting the Certification of Completion?
C' Applicant
r Agent
f Certified Professional
Applicant's Certification
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.
Agent's Certification
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.
If the project was designed by a Certified Professional:
I, as a duly registered Professional 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.
Type of Registered Professional: J

Registration #:
rJ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of the "Certificate of Completion" form is a"transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions AcY')
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions AcY');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Certificate of Completion" form."
Printed Name: Chris Murray
Signature Sign