20141004 Ver 1_Certification of Completion_20141027

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E Skvarla, III
Governor �' (�� Secretary
DWR Project No: Jg' A /PeAc B,q#.tso County: N-10 w et �
Applicant: M
Project Name: 1D c./e C AQ 4r- V4 .,J k 0 ShQ",J« St" n
401 Water Quality Certification Issued Date: 17—//0-
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules,
and any subsequent modifications, the applicant is required to return this certificate to the DWR 401 & Buffer
Permitting Unit, Mail Service Center, Raleigh, NC, 27699 4. This form may be returned to DWR by
the applicant, the applicant's authorized agent, or the project engineer It is not necessary to send
certificates from all of these.
Applicant's Certification
hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications,,and other supporting materials.
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Agent's Certification
I, , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature:
Date:
if this project was designed by a Certified Professional
I, , as a duly registered Professional (i.e., Engineer,
Landscape Architect, Surveyor, etc ) in the State of North Carolina, having been authorized to observe
(periodically, weekly, full time) the construction of the project, for the Permittee hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature.
Date:
Division of Water Resources - 401 & Buffer Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699 -1617
Location 512 N Salisbury St Raleigh, North Carolina 27604
Phone 919 - 807 -63001 FAX 919 - 807 -6494
Internet vvvvw ncwaterquality org
An Equal Opportunity 1 Affirmative Action Employer— Made in part by recycled paper
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