20161049 Ver 1_Certification of Completion_20171229

Action History (UTC -05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/29/2017 12:48:24 PM (Start)
BIMS Updated by Montalvo, Sheri A 1/2/2018 9:09:02 AM (Non DOT Project)
• The task was assigned to Montalvo, Sheri A 12/29/2017 12:48 PM

Water Resources
ENVIRONMENTAL QUALITY
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 ansvered.
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?* r Yes
rJ No
DWR Project #:* Version:*
161049 0
County: Iredell
401 Water Quality Certification Issued Date:
11/14/2016
Applicant: Martin D. Merholz
Project Name: Shoreline Stabilization Pine Isle S/D,
Lot 37, Lake Norman
Supplemental Attachments: Click the upload button or drag and drop files here to attach docurrent
FDF only
Who will be submitting the Certification of
Completion?*
r Applicant
r Agent
f 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.
* V By checking the box and signing box below, I certify that
• I have given true, accurate, and complete information on this form;
• 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")
• 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");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the "Certificate of Completion" form."
Printed Name:* Martin D Merholz

Signature