NCC202792_Modification Review_20210416

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/15/2021 11:06:58 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/16/2021 6:35:15 AM (Construction COC ADD TO FILE Review- NCC202792)
• The task was assigned to Georgoulias, Bethany. The due date is: April 20, 2021 5:00 PM
4/15/2021 11:07 AM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC202792
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Wexford Reserve Ph1 Lot 6
Address
2725 Trifle Ln, Wake Forest, NC
County
Wake
Latitude
35.9982
Longitude
-78.5452
Permittee Listed
Stellar Blu Construction
Legally Responsible
Kimberly Walters
Individual
NC Reference No.
NCG01-2020-2792
E&SC Plan ID
SEC-038985-2020
Original NOI
27663
Tracking No.*
Date COC Issued*
07/02/2020
Prior Rescission
This field will populate only if CCChas already been rescinded.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 and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Remove lot 105 from the certificate of coverage.
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-038989-2020 Certificate of Completion_Lot
135.33KB
105. pdf
Wst 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).
� 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* Kimberly Walters
Title * President
Organization* Stellar Blu Construction
Date * 04/15/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9194578402
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 04/16/2021
Rescinded Since
Submitted?

Request Date 20210415
Formatted
Review Date 20210416
Formatted