NCC205277_Modification Review_20210122 (2)

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/22/2021 8:59:42 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 1/22/2021 1:21:48 PM (Construction COC ADD TO FILE Review- NCC205277)
• The task was assigned to Georgoulias, Bethany. The due date is: January 27, 2021 5:00 PM
1/22/2021 8:59 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC205277
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Morgan Ridge Lot 3
Address
90 Morgan Ridge Way, Chapel Hill, NC
County
Chatham
Latitude
35.8679
Longitude
-79.1587
Permittee Listed
J. Fuller Homes, LLC.
Legally Responsible
James Anderson
Individual
NC Reference No.
NCG01-2020-5277
E&SC Plan ID
2020-05827
Original NOI
36079
Tracking No.*
Date COC Issued*
11/18/2020
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This field will populate only if CCChas already been rescinded.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 and/or Site Contact Has Changed
f Multiple Reasons (List)
Addional IVbre information if needed (e.g., new Site Contact details can be included here)
Explanation
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 Docurrentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Letter of Approval_Morgan Ridge Lot 13.pdf 287.49KB
Letter of Approval_Morgan Ridge Lot 15.pdf 287.51 KB
Wst be FDFforrrat
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).
� 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* James F. Anderson
Title * President
Organization* J. Fuller Homes, LLC.
Date * 01 /22/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 5853709276
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional errail for conf irrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 01/22/2021
Rescinded Since
Submitted?

Request Date 20210122
Formatted
Review Date 20210122
Formatted