20150150 Ver 1_Certification of Completion_20160111

M
NCDENR
North Carolina Department of Environment and
Pat McCrory
Governor
DWR Project No: 1 5- o l 5 o County:
Applicant: C1;-4 of CIG dc,Aie
Project Name: 3121 M n'l-c nod Place K
401 Water Quality Certification Issued Date: 07--- ( i
Certificate of Completion
Natural Resources
Donald R. van der Vaart
Secretary
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, 1650 Mail Service Center, Raleigh, NC, 27699-1650. 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
I, u■ ' n j IA.yr P ✓ ( rAp/U S )— 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 specification , and other supporting materials.
Signature: /� /�/��Jy Date:
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:
If this project was designed by a Certified Professional
Date:
1, , 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, forthe Permitee 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$07-63001 FAX: 919-&07-6492
Internet weAmcnvaterclualily.org
An Equal Opportunity%Alflrmatve Action Employer—Made in padby recycled paper
1 2016