NCC190509_Modification Review_20191205

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/4/2019 4:11:24 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 12/5/2019 6:58:13 AM (Construction COC ADD TO FILE Review- NCC190509)
• The task was assigned to Georgoulias, Bethany. The due date is: December 9, 2019 5:00 PM
12/4/2019 4:11 PM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC190509
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Wendell Falls Residential Lots for Homes by Dickerson
Address
Wendell Falls Parkway/Daniel Ridge Road, Wendell, NC
County
Wake
Latitude
35.7711
Longitude
-78.4261
Permittee Listed
Homes by Dickerson
Legally Responsible
Jonathan Showalter
Individual
NC Reference No.
NCG01-2019-0509
E&SC Plan ID
SEC-08061-2019
Original NOI
11789
Tracking No.*
Date COC Issued*
06/06/2019
Prior Rescission
This field will populate only ff ODChas already been rescinded.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 Multiple Reasons (List)
Addional ivbre infornation if necessary
Explanation Adding Lots 959-962, 969-976 to current NCG01
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).

Supporting Upload Supporting Documentation (%vised ESCApproval, (lose -Out Doc, etc.)
Documentation 19.12.4 Approval Letter.pdf 278.74KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) 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 Artide; 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).
17 I, as an authorized representative, 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.
*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
0'&11tlr1z1eI-Ay Est
Type Name* Jonathan M Showalter
Title * VP, COO
Organization* Homes by Dickerson
Date * 12/04/2019
Email Address* [e-mail]
Email for Confirmation
Telephone Number* 9198474447
Contact Nurrber if we need to reach you
Date Formatted 20191204