NCC204723_Modification Review ADD LOT 5_20210816

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/15/2021 12:49:45 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/16/2021 3:48:19 PM (Construction COC ADD TO FILE Review -
NCC204723)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 19, 2021 5:00 PM
8/15/2021 12:49 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC204723
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Prescott Lot 70
Address
7925 Woodcross Way, Wake Forest, NC
County
Wake
Latitude
36.0090
Longitude
-78.6080
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2020-4723
E&SC Plan ID
SEC-046331-2020
Original NOI
33294
Tracking No.*
Date COC Issued*
10/20/2020
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This field will populate only if CCChas already been rescinded.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 5 Prescott Manor
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 IRSCApproval, (lose -Out Doc, etc.)
Documentation SEC-063274-2021- Prescott Manor Lot 5
284.09KB
_Approval- S&E_SingleLot_PlanReviewChecklist.pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) 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).
� 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* Colleen M Cunningham
Title * President
Organization* Brandywine Homes. Inc.
Date * 08/15/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 919-554-3351
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional errailfor confirrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 08/16/2021
Rescinded Since
Submitted?

Request Date 20210815
Formatted
Review Date 20210816
Formatted