NCC193298_Modification Review LOTS 1112-1115_20210806

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/6/2021 10:40:08 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/6/2021 10:55:03 AM (Construction COC ADD TO FILE Review -
NCC193298)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 11, 2021 5:00 PM
8/6/2021 10:40 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC193298
Coverage (COC) Enter the Certificate of Coverage Ninber (use capital letters)
No.*
Information associated with this permit
Project Name
Academy at Anderson Creek Club S/D PH7 Lots 1099,1100, & 1101
Address
113 Education Dr, Anderson Creek Township, NC
County
Harnett
Latitude
35.2804
Longitude
-78.9714
Permittee Listed
Capitol City Homes LLC
Legally Responsible
Jason Morrow
Individual
NC Reference No.
NCG01-2019-3298
E&SC Plan ID
HARNE-2020-051
Original NOI
19837
Tracking No.*
Date COC Issued*
12/20/2019
Prior Rescission
This field will populate only if COChas already been rescinded.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 Ivbre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Add Lots 1112, 1113, 1114 & 1115
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 ESCApproval, (lose -Out Doc, etc.)
Documentation Approval Letter harne-2021-149.pdf 97.72KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Jason Morrow
Title * Managing Partner
Organization* Capitol City Homes
Date * 08/06/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9198720048
Contact nun ber 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 08/06/2021
Rescinded Since
Submitted?

Request Date 20210806
Formatted
Review Date 20210806
Formatted