20201591 Ver 1_401 Application_20210324

Staff Review Form •
NORFH CA.,i0:INA
En vironmenfrr!QvoGry
Updated September 4,2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
6* Yes r No
ID#* Version* 1
20201591
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Donna Hood:eads\drhood
Select Reviewing Office:* Mooresville Regional Office-[phone]
Does this project require a request for payment to be sent?*
Yes
r
No

Project Submittal Form
Please note:fields marked with a red asterisk *below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type:* r For the Record Only(Courtesy Copy)
r New Project
r Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
r Pre-Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Project Contact Information
Name: Jeff Wyatt
who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Project Name: Replace Cleveland 329
Is this a public transportation project?
r Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown
TIP#: WBS#:
17BP.12.R.42
(Applies to DOT projects only)
County(ies)
Cleveland
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
17BP.12.R.42_Permit Drawings_20210218.pdf 1.35MB
Revised_17BP12R42_MCD_Checklist.pdf 3.13MB
Only pdf or krre files are accepted.
Describe the attachments
or comments:
Permit drawings showing <40ft with signed MCDC maps and cultural resources NSR's
Sign and Submit
17 By checking the box and signing box below, I certify that:
• I,the project proponent, hereby certifies that all information contained herein is true,accurate, and complete to
the best of my knowledge and belief.

• I,the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
• I agree that submission of this online 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 online form.
Signature:
Submittal Date: Is filled in autorretically.