NCC216772_Modification Review_20220922

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/20/2022 11:30:47 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 9/22/2022 10:47:16 AM (Construction COC ADD TO FILE Review - NCC216772)
• The task was assigned to Georgoulias, Bethany A. The due date is: September 23, 2022 5:00 PM
9/20/2022 11:30 AM

Certificate of NCC216772
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name Clouds Harbor -Phase 1
Address 5864 Clouds Harbor Trl, Clemmons, NC
County Forsyth
Latitude 36.0000
Longitude-80.0000
Permittee Listed Clayton Properties Group, inc (dba Shugart Homes)
Legally Responsible Will Derrickson
Individual
NC Reference No. NCG01-2021-6772
E&SC Plan ID EN2100133
Original NOI Tracking 75042
No. *
Date COC Issued* 12/08/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* • Additional Lots/Outparcels Approved - E&SC Revised
Other Revision(s) to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers
Revised plans for Phase II. Lots 15-23, 33-40, & 75-86.
City of Winston-Salem Approval Email Attached.
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload
applicable sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (Revised E&SC Approval, Close -Out Doc, etc.)
Documentation Approval Email.pdf 257.3KB
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* I hereby request modification to coverage under the NPDES Stormwater Permit for the
subject project site. I am familiar with the information contained in this request and to
the best of my knowledge and belief such information is true, complete and accurate.
Specify if you are:* • The Legally Responsible Individual
Authorized Responsible Person*
*This form must be signed by a responsible corporate officer that owns or operates the construction activity, such as a
president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Will Derrickson
Title* Land Development Manager
Organization* Shugart/Mungo Homes
Date * 09/20/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 336-979-4054
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 09/22/2022
Rescinded Since
Submitted?