NCC200767_Modification Review ADD LOT 6_20210712

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/9/2021 8:39:36 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 7/12/2021 8:15:33 AM (Construction COC ADD TO FILE Review -
NCC200767)
• The task was assigned to Georgoulias, Bethany A. The due date is: July 14, 2021 5:00 PM
7/9/2021 8:39 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC200767
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Lot 10 Southern Hills Subdivision
Address
1616 Estate Valley Lane, Bartons Creek, NC
County
Wake
Latitude
35.9608
Longitude
-78.6903
Permittee Listed
Loyd Builders, LLC
Legally Responsible
Frank Loyd
Individual
NC Reference No.
NCG01-2020-0767
E&SC Plan ID
SEC-032812-2020
Original NOI
22295
Tracking No.*
Date COC Issued*
03/26/2020
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This field will populate only if CCChas already been rescinded.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 Nbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Add Lot 6 as additional lot.
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 I&SC Approval, (lose -Cut Doc, etc.)
Documentation SEC-061570-2021 Lot 6 Southern Hills Approval-
294.11 KB
S&E_SingleLot_PlanReviewChecklist. pdf
Wst be FDFfornat
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
llirr11� 1�t- I Z1-�
Type Name* Frank R. Loyd, III
Title * Manager
Organization* Tripp Loyd Builders
Date * 07/09/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9193871455
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/12/2021
Rescinded Since
Submitted?

Request Date 20210709
Formatted
Review Date 20210712
Formatted