NCC211962_Modification Review_20210827

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/25/2021 3:21:35 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/27/2021 9:56:36 AM (Construction COC ADD TO FILE Review -
NCC211962)
• The task was assigned to Georgoulias, Bethany A. The due date is: August 30, 2021 5:00 PM
8/25/2021 3:21 PM

Y . Ta4M1
w,
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC211962
Coverage (COC)
Enter the Certificate of Coverage Ninber (use capital letters)
No.*
Information associated
with this permit:
Project Name
Brooke Hill Subdivision
Address
635 Hauser Road, Lewisville, NC
County
Forsyth
Latitude
36.0908
Longitude
-80.4538
Permittee Listed
RS Parker Homes LLC
Legally Responsible
Daniel Greene
Individual
NC Reference No.
NCG01-2021-1962
E&SC Plan ID
EN2100036
Original NOI
48805
Tracking No.*
Date COC Issued*
04/01/2021
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This field will populate only if CCChas already been rescinded.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 * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Disturbance area updated
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 -Cut Doc, etc.)
Documentation GRADING PERMIT-REV1.pdf 648.32KB
Mast be PDFformat
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
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* Daniel Greene
Title * Manager
Organization* IRS Parker Homes, LLC
Date * 08/25/2021
Email Address* [e-mail]
Errail for confirrration
Telephone Number* 336-252-2781
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 errail for confirrration
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 08/27/2021
Rescinded Since
Submitted?

Request Date 20210825
Formatted
Review Date 20210827
Formatted