NCC211661_Modification Review to ADD LOTS 1 6 7 9_20210729

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/28/2021 7:59:04 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 7/29/2021 7:07:26 AM (Construction COC ADD TO FILE Review -
NCC211661)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 2, 2021 5:00 PM
7/28/2021 7:59 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC211661
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Briarcliffe Village SFD Construction
Address
2707 Zuni Court, Winston Salem, NC
County
Forsyth
Latitude
36.1448
Longitude
-80.3037
Permittee Listed
The Veritas Group, Inc.
Legally Responsible
Michael Enscore
Individual
NC Reference No.
NCG01-2021-1661
E&SC Plan ID
500853
Original NOI
48013
Tracking No.*
Date COC Issued*
03/19/2021
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This field will populate only if CCChas already been rescinded.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 MDre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Covers modified disturbed acres for the original lots + new disturbed area for new
lots 1, 6, 7, & 9
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 (Revised E&SCApproval, nose -Out Doc, etc.)
Documentation Review Completed - Lots 1 & 9 Briarcliffe Village
149.96KB
SFD Construction. pdf
Mast be FDFfornat
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
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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
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Type Name* Michael S. Enscore
Title * President / Owner
Organization* The Veritas Group, Inc.
Date * 07/28/2021
Email Address* [e-mail]
Errail for confirrration
Telephone Number* 336-404-1522
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional en -ail for confirnation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/29/2021
Rescinded Since
Submitted?

Request Date 20210728
Formatted
Review Date 20210729
Formatted