20150467 Ver 1_Certification of Completion_20200603

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/3/2020 5:26:57 PM (Start)
BIMSUpdated by Carpenter, Kristi 6/4/2020 10:49:08 AM (DOT Project)
• The task was assigned to Carpenter, Kristi 6/3/2020 5:27 PM

Staff Review
DWR Project #:* 20150467 Version:* 1
Reviewer List* Joanne Steen h u is:eads\jhsteen h u is
CERTIFICATION SUBMITTED ON 6/3/2020
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 submit it to the DWR 401 & Buffer Permitting Branch. 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.
Is this a Public Transportation Project? fJ Yes
r No
USACE Permit# SAW-2014-01705
DWR Project M 20150467 Version: 1
County: Pender
401 Water Quality Certification Issued Date:
5/20/2015
Applicant: NCDOT - Division 3
Project Name: SR 1764 Copperhead Lane
Supplemental Attachments: Clickthe upload bultonordrag and drop fHas here toattach docurrent
SR 1764_Coperhead Lane-401
1.17MB
completion form. pdf
SR 1764_Coperhead Lane_404
60.07KB
completion form.pdf
FDF only
Who will be submitting the Certification of Completion?
r Applicant
r Agent
f Certified Professional
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.
fJ 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 Act')
0 1 agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
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: Anneliese Westphal
Signature
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