NCC211293_Modification Review ADD LOT 43_20210623

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/23/2021 10:17:02 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/23/2021 3:15:21 PM (Construction COC ADD TO FILE Review -
NCC211293)
• The task was assigned to Georgoulias, Bethany A. The due date is: June 28, 2021 5:00 PM
6/23/2021 10:17 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC211293
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Laurel Ridge
Address
128 Bluffside Court, Pittsboro, NC
County
Chatham
Latitude
35.8040
Longitude
-79.2120
Permittee Listed
Cotton Custom Homes
Legally Responsible
William Cotton
Individual
NC Reference No.
NCG01-2021-1293
E&SC Plan ID
LDP 21_82
Original NOI
46107
Tracking No.*
Date COC Issued*
03/04/2021
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This field will populate only if CCChas already been rescinded.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
r Multiple Reasons (List)
Addional We inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Lot 43 is being added - address is 228 Blufftonwood, Pittsboro
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 43 LR Approval Letter for e-NOI.pdf 136.85KB
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 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* Anita Becker
Title * Office Manager
Organization* cotton custom homes
Date * 06/23/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9193678615
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 06/23/2021
Rescinded Since
Submitted?

Request Date 20210623
Formatted
Review Date 20210623
Formatted