NCC204693_Modification Review LOTS 44 46 65_20201019

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/17/2020 6:45:34 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/19/2020 7:47:59 AM (Construction COC ADD TO FILE Review- NCC204693)
• The task was assigned to Georgoulias, Bethany. The due date is: October 22, 2020 5:00 PM
10/17/2020 6:45 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC204693
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Prescott Manor Ph 1, Lot 21
Address
952 Harrison Ridge Rd, Wake Forest, NC
County
Wake
Latitude
36.0100
Longitude
-78.6050
Permittee Listed
Stellar Blu Construction
Legally Responsible
Kimberly Walters
Individual
NC Reference No.
NCG01-2020-4693
E&SC Plan ID
SEC-460000-2020
Original NOI
33248
Tracking No.*
Date COC Issued*
10/16/2020
Prior Rescission
This field will populate only if CCChas already been rescinded.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 Nbre information if necessary
Explanation Addition of Prescott Manor Ph 1 Lots 44, 46, and 65
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 SEC-046002-2020 Prescott Manor PH 1 lot 44
305.18KB
Approval S&E_SingleLot_PlanReviewChecklist.pdf
SEC-046003-2020 Prescott Manor PH 1 lot 46
304.74KB
Approval S&E_SingleLot_PlanReviewChecklist.pdf
SEC-046004-2020 Prescott Manor PH 1 lot 65
305.09KB
Approval S&E_SingleLot_PlanReviewChecklist.pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
rJ 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
f 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
&Ai"
Type Name* Kimberly Walters
Title * President
Organization* Stellar Blu Construction, Inc
Date * 10/17/2020
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 919-345-1924
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-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email

Review Date 10/19/2020
Rescinded Since
Submitted?
Request Date 20201017
Formatted
Review Date 20201019
Formatted