20050213 Ver 1_Certification of Completion_20090520

Certification of Completion
DWQ Project No
Applicant:
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Project Name:
0 ?- 0 -Z I - County:
Date of Issuance of Isolated Wetland Permit:
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Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North Carolina
Division of Water Quality, 160 Mail Service Center, Raleigh, NC, 27699-160. This form may be returned to DWQ 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
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hereby state that, to the best of m abilities due care a
used in the observation of the construction such that the construction was observed to be built with nllrsubstan al
compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications,
and other suppo 'n materials.
Signature:
Date:
Agent's Certification
1. , 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 designee[ by a Certified Professional f v
as a duly registered rofessional
(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:
Registration No.
Date
MA,( 2 0 2009
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Permit Number: 20053133.9
'Permit Type: GP30 '
Name of County: Jackson
Name of Permittee: David and Sherry Sims . •
Date of Issuance: March 9, 2005
Project Manager: Debbie Miller
Upon completion of the activity authorized by this pen-nit and any mitigation required by the
permit, sign this certification and return it to the following address:
U.S. Army Corps of Engineers
Attention: CESAW-RG-A
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
Please note that your permitted activity is subject to a compliance inspection by an U.S. Army
Corps of Engineers representative. If you fail to comply with this permit you are subject to
permit suspension, modification, or revocation.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the tenns and conditions of the said pennit, and required mitigation was
completed in accordance with the permit conditions.
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Sig ure of ermi ee Date /
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