NCC191644_Modification Review ADD 3 LOTS_20201123

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/23/2020 12:59:21 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 11/23/2020 1:05:41 PM (Construction COC ADD TO FILE Review- NCC191644)
• The task was assigned to Georgoulias, Bethany. The due date is: November 26, 2020 5:00 PM
11/23/2020 12:59 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC191644
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Chapel Ridge Lot 391 and 450
Address
201 Cabin Creek and 192 Deep Creek, Pittsboro, NC
County
Chatham
Latitude
35.7800
Longitude
-79.2000
Permittee Listed
MJ Rose Homes
Legally Responsible
Martin Beam
Individual
NC Reference No.
NCG01-2019-1644
E&SC Plan ID
2019-06985
Original NOI
15388
Tracking No.*
Date COC Issued*
08/30/2019
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This field will populate only if COChas already been rescinded.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 Has Changed
r Multiple Reasons (List)
Addional We information if necessary
Explanation Adding three additional lots to the permit. All within the same community.
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 Letter of Approval_Chapel Ridge Lots 103, 129 &
1.13MB
410 MJ Rose. pdf
Wst 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
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* Martin Beam
Title * Manager
Organization* MJ Rose Homes
Date * 11 /23/2020
Email Address* [e-mail]
En -ail for confin- ation
Telephone Number* 9193693714
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ration
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 11/23/2020
Rescinded Since
Submitted?

Request Date 20201123
Formatted
Review Date 20201123
Formatted