20200767 Ver 1_Certification of Completion_20230919 (2)

Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
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 submit it to the DWR 401 & Buffer Permitting Branch. 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.
Is this a Public Transportation Project?* ❑ Yes
Q No
USACE Permit# SAW-2019-00556
DWR Project #: * 200767
County:* Cabarrus
Applicant: * Old Holland Road, LLC
Version: *
401 Water Quality Certification Issued Date:
7/7/2020
Project Name: * The Addison
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
20-0767 Addison DWR Letter of Approval
828.99 KB
Last Page to be Completed.pdf
20-0767 DWR Last Page Signed.pdf 452.96KB
SAW-2019-00556 (signed NWP).pdf 2.35MB
PDF only
Who will be submitting the Certification of Completion?*
Applicant
Agent
Certified Professional
Applicant'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.
* By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of the "Certificate of Completion" form is a "transaction" subject to Chapter 66, Article 40 of the
NC General Statutes (the "Uniform Electronic Transactions Act")
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act");

o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the "Certificate of Completion" form."
Printed Name:* John Schaffer
Signature* 0�&&v