20181089 Ver 1_Certification of Completion_20210203 (2)

Certification of Completion
Please note: fields mark ed with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
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 Proje ct?*
USACE Pe rmit#
DWR Proje ct #:*Ve rsion:*
County:*
401 Wate r Quality Ce rtification Issue d Date :
Applicant:*
Proje ct Name :*
Supple me ntal Attachme nts:
Who will be submitting the Ce rtification of
Comple tion?*
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.
*
I have given true, accurate, and complete information on this form;
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”)
I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the “Uniform Electronic Transactions Act”);
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
I intend to electronically sign and submit the "Certificate of Completion" form.”
Yes
No
SAW-2018-01799
181089 1
Chatham 9/19/2018
DANIEL KUGLER
KUGLER, DANIEL/POND SITE RESTORATION PROJECT
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Applicant
Agent
Certified Professional
Applicant's Ce rtification
By checking the box and signing box below, I certify that:
Printe d Name :*
Signature *
DANIEL KUGLER