NCC212034_Modification Review ADD LOT 6_20210616

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/16/2021 8:41:17 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/16/2021 2:50:06 PM (Construction COC ADD TO FILE Review -
NCC212034)
• The task was assigned to Georgoulias, Bethany A. The due date is: June 21, 2021 5:00 PM
6/16/2021 8:41 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC212034
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Barham Reserve
Address
7024 Will Let Lane, Wake County, NC
County
Wake
Latitude
35.9361
Longitude
-78.3958
Permittee Listed
Winslow Custom Homes
Legally Responsible
Matthew Winslow
Individual
NC Reference No.
NCG01-2021-2034
E&SC Plan ID
SEC-055390-2021
Original NOI
49377
Tracking No.*
Date COC Issued*
04/05/2021
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This field will populate only if CCChas already been rescinded.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
f Multiple Reasons (List)
Addional IVbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nurTbers.
Explanation
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 Docurrentation (%vised I&SC Approval, (lose -Out Doc, etc.)
Documentation SEC-059263-2021 Barham Reserve Lot 6
271.56KB
Approval- S&EConstructionPlan Review .... pdf
Wst be FDFformat
North Carolina General Statute 143-215.6113 (i) 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 Artide 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 Artide 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).
� 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* Matthew Winslow
Title * Manager
Organization * Winslow Custom Homes, LLC
Date * 06/16/2021
Email Address* [e-mail]
En -ail for confirmation
Telephone Number* 9195564700
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/16/2021
Rescinded Since
Submitted?

Request Date 20210616
Formatted
Review Date 20210616
Formatted