NCC203239_Modification Review_20210308

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/8/2021 12:55:08 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 3/8/2021 2:10:59 PM (Construction COC ADD TO FILE Review- NCC203239)
• The task was assigned to Georgoulias, Bethany. The due date is: March 11, 2021 5:00 PM
3/8/2021 12:55 PM

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NORTH CAPOLINA
EnYlmnmPnf& Qualify
Certificate of NCC203239
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Gallagher Residence
Address
3609 Piaffe Avenue, Mint Hill, NC
County
Mecklenburg
Latitude
35.1575
Longitude
-80.6582
Permittee Listed
Arcadia Homes INC
Legally Responsible
Daniel Queen
Individual
NC Reference No.
NCG01-2020-3239
E&SC Plan ID
411281
Original NOI
29004
Tracking No.*
Date COC Issued*
08/04/2020
Prior Rescission
This field will populate only if CDC has already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional We information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation .19 Acer added inside LOD
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 ESCApproval, (lose -Out Doc, etc.)
Documentation EC Doc -Approved Itr #419619.pdf 141.22KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) 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 e)ceed 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
r 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* Phillip Stapp
Title * Assistant Construction Manager
Organization * ARCADIA Custom Homes
Date * 03/08/2021
Email Address* [e-mail]
Errail for confirrration
Telephone Number* 7049627906
Contact nun ber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 03/08/2021
Rescinded Since
Submitted?

Request Date 20210308
Formatted
Review Date 20210308
Formatted