NCC205670_Modification Review_20210503

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/30/2021 3:23:28 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 5/3/2021 11:09:06 AM (Construction COC ADD TO FILE Review -
NCC205670)
• The task was assigned to Georgoulias, Bethany A. The due date is: May 5, 2021 5:00 PM
4/30/2021 3:23 PM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC205670
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit:
Project Name MASON OAKS SUBDIVISION- LOTS 33, 204, 205
Address HWY US 1 @ MASON OAKS DRIVE, WAKE FOREST, NC
County Franklin
Latitude 36.0171
Longitude-78.5137
Permittee Listed NVR, Inc.
Legally Responsible MEREDITH SWEITZER
Individual
NC Reference No. NCG01-2020-5670
E&SC Plan ID
Original NOI
Tracking No.
2020-00002610
38118
Date COC Issued* 12/09/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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
r Multiple Reasons (List)
Addional We information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation ADDITION OF LOTS 250, 251
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 ERSC Approval, (lose -Out Doc, etc.)
Documentation MASON OAKS- LOTS 250, 251- LOA.pdf 95.34KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) 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 Article 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 Article 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).
17 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
jot lro/w
Type Name* JOE SCHMIDTKE
Title * VICE PRESIDENT
Organization* NVR, Inc.
Date * 04/30/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9199871930
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 05/03/2021
Rescinded Since
Submitted?

Request Date 20210430
Formatted
Review Date 20210503
Formatted