NCC190509_Modification Review_20201026 (2)

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/23/2020 4:48:47 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/26/2020 7:59:29 AM (Construction COC ADD TO FILE Review- NCC190509)
• The task was assigned to Georgoulias, Bethany. The due date is: October 28, 2020 5:00 PM
10/23/2020 4:48 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
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
36.0000
Longitude
-78.0000
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This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for F Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
O Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
r Multiple Reasons (List)
Addional We information if necessary
Explanation Modifying to remove lots 964, 994, 1036, and 1039 in SEC-018061-2019 and also
removing lot 970 and 974 in SEC-029075-2019
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 IBSCApproval, (lose -Out Doc, etc.)
Documentation SEC-018061-2019 Certificate of
142.33KB
Completion_Multiple Lots_9-30-20.pdf
SEC-029075-2019 Certificate of
142.32KB
Completion_Lots970974_9-30-20. pdf
%st 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).
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
Type Name* Jon Showalter
Title * COO / VP
Organization* Homes by Dickerson
Date * 10/23/2020
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9198474447
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 10/26/2020

Rescinded Since
Submitted?
Request Date 20201023
Formatted
Review Date 20201026
Formatted