Loading...
HomeMy WebLinkAbout2022-144-E-AMS-BBUDC-OCPT Septic Upgrades Amend the scope of workRevised 06/21 ORANGE COUNTY CHANGE ORDER REQUEST NORTH CAROLINA ______________________________________________________________________________________________________________ Date: 4/4//2022 Project: OCPT Septic Upgrades Change Order No. 02 Department: AMS Department Address: 300 West Tryon Street, Hillsborough, NC 27278 Project: Orange County Public Transportation Septic Upgrades Contractor: BBUDC, Inc Contractor Address: PO Box 52552, Durham, NC 27717 Effective date of original contract: 1/28/2022 This change order increases decreases the contract time by 24 days. Check here if no impact to contract time . Will this change order impact the date of substantial completion? Yes No. If yes, the amended date of substantial completion is: July 24, 2022 _______________________________________________________________________________________________________________ Full Description of Change: Scope Clarifications are as follows: Pipe Size: As per the approved variance requested by the State Plumbing office all pipe sizes shall be 4” (four inches) in diameter. Pipe Type: All piping shall be SCH 40 PVC with the expectation in traffic areas. The piping in traffic areas shall be DI pipe. Cleanouts: Cleanouts are required every 100 feet and where there are angles in the pipe. All cleanouts shall be SCH 40 PVC expect in traffic areas shall be traffic rated. Stone Base: 4” (four inch) stone base is only required in unsuitable soil and in traffic areas. Contractor may use 4” (four inch) stone base and/or screening (SCGS) in other areas than unsuitable soil or traffic areas at no additional cost to the owner. Slope: The slope for the installed piping shall be field verified and adjusted to meet the minimum plumbing code requirements. Table 704.1 Slope of Horizontal Drainage Piping attached for reference. 704.1 States the following: “Horizontal drainage piping shall be installed in uniform alignment at uniform slopes. The slope of a horizontal drainage pipe shall not be less than that indicated in Table 704.1.” Inspections: Contractor shall coordinate with the Authority Having Jurisdiction (AHJ) for all inspections. Including but not limited to local, state or federal as required to obtain approvals per the approved permits. Reason for Change: Amend and update the contract to reflect the acceptable changes in the scope, and extend the contract by the allowable days pending the clarifications. _______________________________________________________________________________________________________________ Original contract sum: $ 48,705.00 Contract sum prior to this change order: $ 63,205.00 Amount of this change order: $ 0.00 Total sum of the contract including this change order: $ 63,205.00 DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Revised 06/21 _______________________________________________________________________________________________________________ This change order is executed to amend the contract time or contract sum. It shall not be construed to impact the original contract, project, services, or work in any other manner. All other terms of the Original Contract remain in effect. Approved and executed this 4th day of April, 2022. _______________________________ _____________________________ _____________________________ Contractor Owner Architect (when retained) By:____________________________ By:___________________________ By:___________________________ DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 4/4/2022 Donald Sever - Summit DesignCEO 4/14/2022 4/15/2022 County Manager Revised 06/21 ORANGE COUNTY—DEPARTMENT USE ONLY _____________________________________________________________________________________________________ Party/Vendor Name: BBUDC, Inc Party/Vendor Contact Person: Isaac Woods (BBUDCINC@Gmail.com) Contact Phone: 919.913.8339 Party/Vendor Address: PO Box 52552 City Durham State: NC Zip: 27717 Department: AMS Amount: $0.00 Purpose: OCPT Septic Upgrades - Amend the scope of work Budget Code(s): 61370035-880000-10075 Vendor # 66716 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date - Original Contract 1/28/2022, Change Order No. 02 March 29, 2022 Approved by Board Yes No Agenda Date: 1/18/2022 --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this pro ject has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: N/A Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign cont racts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 4/14/2022 4/14/2022 4/14/2022 4/15/2022 August 27, 2021 Angel Barnes, Capital Project Manager abarnes@orangecountync.gov Orange County PO Box 8181 Hillsborough, NC 27278 Subject: Permit No. WQ0042650 Orange County Orange County Public Transportations Septic Improvements Wastewater Collection System Extension Permit Orange County Dear Permittee: In accordance with your application received June 30, 2021, and variance approval on July 7, 2021, we are forwarding herewith Permit No. WQ0042650 dated August 27, 2021, to the Orange County Permittee) for the construction and operation upon certification of the subject wastewater collection system extension. This permit shall be effective from the date of issuance until rescinded and shall be subject to the conditions and limitations as specified therein. This cover letter shall be considered a part of this permit and is therefore incorporated therein by reference. Please pay particular attention to the following conditions contained within this permit: Condition I.1: Per the submitted variance request as received on June 30, 2021 by Summit Design and Engineering Service on behalf of Orange County for the subject project, the Division will grant the variance request for approximately 1,200 linear feet of existing 4-inch public gravity sewer in lieu of the minimum of 8-inch as required for public gravity sewer lines per 15A NCAC 02T.0305(i)(1) in accordance with the provisions for alternative design under 15A NCAC 02T.0105(n). Regardless of the variance approval, in the event that the wastewater collection facilities fail to perform satisfactorily, including the creation of nuisance conditions, the Permittee shall take immediate corrective action, including those as may be required by this Division, such as the construction of additional or replacement facilities. All other elements of this project shall be constructed in accordance with all applicable rules and statues including, 15A NCAC 2T; the Division of Water Resources’ (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; and the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable. DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Orange County Permit No. WQ0042560 Page 2 of 8 Condition II.1: This permit shall not be automatically transferable; a request must be made and approved. Condition II.4: Requires that the wastewater collection facilities be properly operated and maintained in accordance with 15A NCAC 02T .0403 or any individual system-wide collection system permit issued to the Permittee. Condition II.7: Upon completion of construction and prior to operation of these permitted facilities, the completed Engineering Certification form with checklist attached to this permit shall be submitted with the required supporting documents to the address provided on the form. Permit modifications are required for any changes resulting in non-compliance with this permit, regulations, or the Minimum Design Criteria. [15A NCAC 02T.0116] It shall be responsibility of the Permittee to ensure that the as-constructed project meets the appropriate design criteria and rules. Failure to comply may result in penalties in accordance with North Carolina General Statute §143-215.6A through §143-215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of the North Carolina-licensed Professional Engineer to the licensing board. If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This request must be in the form of a written petition, conforming to Chapter 150B of North Carolina General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and binding. If you need additional information concerning this matter, please contact Jason Robinson via e-mail at Jason.T.Robinson@ncdenr.gov. Sincerely, for S. Daniel Smith Director, Division of Water Resources by Scott Vinson, Regional Supervisor Water Quality Regional Operations Section Raleigh Regional Office Division of Water Resources, NCDEQ cc: don.sever@summitde.net marie.strandwitz@hillsboroughnc.gov Raleigh Regional Office Files DWR Laserfiche Orange Health Department DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Page 3 of 8 WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the Orange County for the construction and operation of approximately 1,200 linear feet of 8-inch gravity sewer to serve a nine employee building part of the Orange County Public Transportations Septic Improvements project, and the discharge of 225 gallons per day of collected domestic wastewater into the Hillsborough’s existing sewerage system, pursuant to the application received June 30, 2021, and the variance granted on July 7, 2021 (see Special Condition I.1) and in conformity with 15A NCAC 02T; the Division’s Gravity Sewer Minimum Design Criteria adopted February 12, 1996 and updated in March 2008, as applicable; the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting data subsequently filed and approved by the Department of Environmental Quality and considered a part of this permit. This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified conditions and limitations contained therein. for S. Daniel Smith Director, Division of Water Resources By Authority of The Environmental Management Commission Permit Number: WQ0042650 Permit Issued: August 27, 2021 DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Page 4 of 8 SUPPLEMENT TO PERMIT COVER SHEET Orange County is hereby authorized to: Construct, and then operate upon certification the aforementioned wastewater collection extension. The sewage and wastewater collected by this system shall be treated in the Town of Hillsborough’s Wastewater Treatment Facility in accordance with Permit Number NC0026433. Permitting of this project does not constitute an acceptance of any part of the project that does not meet 15A NCAC 02T; the Division’s Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; and the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval is based on acceptance of the certification provided by a North Carolina-licensed Professional Engineer in the application. It shall be the Permittee’s responsibility to ensure that the as-constructed project meets the appropriate design criteria and rules. Construction and operation is contingent upon compliance with the Standard Conditions and any Special Conditions identified below. I. SPECIAL CONDITIONS 1. Per the submitted variance request as received on June 30, 2021 by Summit Design and Engineering Service on behalf of Orange County for the subject project, the Division will grant the variance request for approximately 1,200 linear feet of existing 4-inch public gravity sewer in lieu of the minimum of 8-inch as required for public gravity sewer lines per 15A NCAC 02T.0305(i)(1) in accordance with the provisions for alternative design under 15A NCAC 02T.0105(n). Regardless of the variance approval, in the event that the wastewater collection facilities fail to perform satisfactorily, including the creation of nuisance conditions, the Permittee shall take immediate corrective action, including those as may be required by this Division, such as the construction of additional or replacement facilities. All other elements of this project shall be constructed in accordance with all applicable rules and statues including, 15A NCAC 2T; the Division of Water Resources’ (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; and the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable. 2. This permit shall become voidable unless the agreement between Orange County and Hillsborough for the collection and final treatment of wastewater is in full force and effect. [15A NCAC 02T.0304(g)] II. STANDARD CONDITIONS 1. This permit shall not be transferable. In the event there is a desire for the wastewater collection facilities to change ownership, or there is a name change of the Permittee, a formal permit request shall be submitted to the Division accompanied by documentation from the parties involved, and other supporting materials as may be appropriate. The approval of this request shall be considered on its merits and may or may not be approved. [15A NCAC 02T.0116; G.S 143-215.1(d3)] DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Page 5 of 8 2. This permit shall become voidable unless the wastewater collection facilities are constructed in accordance with the conditions of this permit; 15A NCAC 02T; the Division’s Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110] 3. This permit shall be effective only with respect to the nature and volume of wastes described in the application and other supporting data. [15A NCAC 02T .0110] 4. The wastewater collection facilities shall be properly maintained and operated at all times. The Permittee shall maintain compliance with an individual system-wide collection system permit for the operation and maintenance of these facilities as required by 15A NCAC 02T .0403. If an individual permit is not required, the following performance criteria shall be met: a. The sewer system shall be effectively maintained and operated at all times to prevent discharge to land or surface waters, and to prevent any contravention of groundwater standards or surface water standards. b. A map of the sewer system shall be developed and shall be actively maintained. c. An operation and maintenance plan including pump station inspection frequency, preventative maintenance schedule, spare parts inventory and overflow response has been developed and implemented. d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365 days per year). Pump stations that are connected to a telemetry system shall be inspected at least once per week. e. High-priority sewer lines shall be inspected at least once per every six-months and inspections are documented. f. A general observation of the entire sewer system shall be conducted at least once per year. g. Overflows and bypasses shall be reported to the appropriate Division regional office in accordance with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina General Statute §143-215.1C. h. A Grease Control Program is in place as follows: 1. For public owned collection systems, the Grease Control Program shall include at least biannual distribution of educational materials for both commercial and residential users and the legal means to require grease interceptors at existing establishments. The plan shall also include legal means for inspections of the grease interceptors, enforcement for violators and the legal means to control grease entering the system from other public and private satellite sewer systems. 2. For privately owned collection systems, the Grease Control Program shall include at least bi- annual distribution of grease education materials to users of the collection system by the permittee or its representative. 3. Grease education materials shall be distributed more often than required in Parts (1) and (2) of this Subparagraph if necessary to prevent grease-related sanitary sewer overflows. i. Right-of-ways and easements shall be maintained in the full easement width for personnel and equipment accessibility. DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Page 6 of 8 j. Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of three years with exception of the map, which shall be maintained for the life of the system. 5. The Permittee shall report by telephone to a water resources staff member at the Raleigh Regional Office, telephone number (919) 791-4200, as soon as possible, but in no case more than 24 hours, following the occurrence or first knowledge of the occurrence of either of the following: a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable of adequate wastewater transport, such as mechanical or electrical failures of pumps, line blockage or breakage, etc.; or b. Any SSO and/or spill over 1,000 gallons; or c. Any SSO and/or spill, regardless of volume, that reaches surface water Voice mail messages or faxed information is permissible, but this shall not be considered as the initial verbal report. Overflows and spills occurring outside normal business hours may also be reported to the Division of Emergency Management at telephone number (800) 858-0368 or (919) 733-3300. Persons reporting any of the above occurrences shall file a spill report by completing and submitting Part I of Form CS-SSO (or the most current Division approved form) within five days following first knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to ensure that the problem does not recur. Part II of Form CS-SSO (or the most current Division approved form) can also be completed to show that the SSO was beyond control. [G.S. 143-215.1C(a1)] 6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater to the surface waters of the State. [15A NCAC 02T.0108(b)] 7. Upon completion of construction and prior to operation of these permitted facilities, the completed Engineering Certification form with checklist attached to this permit shall be submitted with the required supporting documents to the address provided on the form. A complete certification is one where the form is fully executed and the supporting documents are provided as applicable. Any wastewater flow made tributary to the wastewater collection system extension prior to completion of this Engineer's Certification shall be considered a violation of the permit and shall subject the Permittee to appropriate enforcement actions. If the permit is issued to a private entity with an Operational Agreement, then a copy of the Articles of Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately filed with the applicable County’s Register of Deeds office shall be submitted with the certification. A complete certification is one where the form is fully executed and the supporting documents are provided as applicable. Supporting documentation shall include the following: a. One copy of the project construction record drawings (plan & profile views of sewer lines & force mains) of the wastewater collection system extension. Final record drawings should be clear on the plans or on digital media (CD or DVD disk) and are defined as the design drawings that are marked up or annotated with after construction information and show required buffers, separation distances, material changes, etc. b. One copy of the supporting applicable design calculations including pipe and pump sizing, velocity, pump cycle times, and level control settings, pump station buoyancy, wet well storage, surge protection, detention time in the wet well, and force main, ability to flush low points in force DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 Page 7 of 8 mains with a pump cycle, and downstream sewer capacity analysis. If a portable power source or pump is dedicated to multiple stations, an evaluation of all the pump stations’ storage capacities and the rotation schedule of the portable power source or pump, include travel timeframes, shall be provided. c. Changes to the project that do not result in non-compliance with this permit, regulations, or the Minimum Design Criteria should be clearly identified on the record drawings, on the certification in the space provided, or in written summary form. Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting in non-compliance with this permit (including but not limited to pipe length changes of 10% or greater, increased flow, pump station design capacity design increases of 5% or greater, and increases in the number/type of connections), regulations, or the Minimum Design Criteria. Requested modifications or variances to the Minimum Design Criteria will be reviewed on a case-by- case basis and each on its own merit. Please note that variances to the Minimum Design Criteria should be requested and approved during the permitting process prior to construction. After- construction requests are discouraged by the Division and may not be approved, thus requiring replacement or repair prior to certification & activation. [15A NCAC 02T .0116] 8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division’s Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until corrected. If there is an unforeseen obstacle in the field where all viable solutions have been examined, a slope variance can be requested from the Division with firm supporting documentation. This shall be done through a permit modification with fee. Such variance requests will be evaluated on a case-by-case basis. Resolution of such request shall be evident prior to completing and submitting the construction certification. [ 15A NCAC 02T.0105(n)] 9. A copy of the individual permit and construction record drawings shall be maintained on file by the Permittee for the life of the wastewater collection facilities. [15A NCAC 02T .0116] 10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 02T; the Division’s Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Station and Force Mains adopted June 1, 2000 as applicable; and other supporting materials may subject the Permittee to an enforcement action by the Division, in accordance with North Carolina General Statutes §143-215.6A through §143- 215.6C, construction of additional or replacement wastewater collection facilities, and/or referral of the North Carolina-licensed Professional Engineer to the licensing board. [15A NCAC 02T .0108(b-c)] 11. In the event that the wastewater collection facilities fail to perform satisfactorily, including the creation of nuisance conditions, the Permittee shall take immediate corrective action, including those as may be required by this Division, such as the construction of additional or replacement facilities. 15A NCAC 02T .0110; 15A NCAC 02T .0108(b)] 12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes, rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local government agencies which have jurisdiction or obtaining other permits which may be required by the Division or any other Federal, State, of Local government agencies. [G.S. 143-215.1(b)] DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 CERTIFICATION CHECKLIST North Carolina Department of Environmental Quality _ Division of Water Resources Raleigh Regional Office _ 1628 Mail Service Center, Raleigh, NC 27699-1628 Physical Address: 3800 Barrett Drive, Raleigh, NC 27609 919-791-4200 To be completed by the certifying engineer prior to operation of the permitted sewers, per 15A NCAC 02T.0116. Certifying Engineer: _______________________________________________________ Certification Review Date: __________________________________________________ Project Name: ____________________________________________________________ WQ00______________ Project County: _______________________________________ 1) Has permittee information changed since the permit was issued (or last modified): change of mailing address, change of ownership, transfer from developer to HOA/POA, etc. Yes No x If yes, please provide either a change of ownership form or new contact information. Note that transfer of permits from the developer to the HOA/POA must occur with the first certification. 2) Have the as-built drawings have been signed, sealed, and dated by an N.C. PE? Yes No 3) Final Engineering certification? Yes No x If Partial Engineering certification, provide detailed narrative including what is being certified in the current phase, what was previously certified (if applicable), and what is left to be certified. 4) Adequate information related to sewer lines: Yes No N/A x Three feet minimum cover has been provided for all sewers unless ferrous pipe was installed. x Minimum diameters for gravity sewers are 8-inches for public lines and 6-inches for private lines. x Manholes have been installed: At the end of each line, at all changes in grade, size, or alignment, at all intersections, and at distances not greater than 425 feet; minimum diameter shall be 4 feet (48-inches). 5) Adequate information related to pump stations: Yes No N/A x Ensure power reliability option was selected per 15A NCAC 02T.0305(h). 6) Was project construction completed in accordance with all of the following: Yes No N/A x 15A NCAC 02T, Minimum Design Criteria (MDC) for the permitting of Gravity Sewers (latest version), and MDC for the Permitting of Pump Stations and Force Mains (latest version)? If not, a variance approval is required in accordance with 15A NCAC 02T.0105(b), prior to certification and operation. x Contact the Central Office to discuss the variance to determine a course of action. x Applicant must submit two copies of the variance request form, plans, specifications, calculations, and any other pertinent information to the Central Office (one hard copy, one digital copy). x The central office will review the variance request, and if approvable, specific language regarding the variance will be incorporated into the permit, either via a special condition or a supplementary letter. A copy of the reissued permit with variance language or the variance letter must be maintained with the original documents. 7) Does the project contains high priority lines (15A NCAC 02T .0402(2))? Yes No x If yes, ensure that the permit already contains the necessary condition related to high priority lines 15A NCAC 02T.0403 (a)(5). If the permit does not include this language, the Fast Track reviewer will reissue the permit with the appropriate language. 8) Are Permit modifications are required for any changes resulting in non-compliance with this permit (including but not limited to pipe length changes of 10% or greater, change in flow, pump station design capacity design change of 5% or greater, and/or change in the number/type of connections)? Yes No x If yes, a permit modification request must be submitted to the appropriate Regional Office, and a modified permit with revised certification must be issued prior to certification and operation. DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 FAST TRACK SEWER ENGINEERING CERTIFICATION North Carolina Department of Environmental Quality _ Division of Water Resources Raleigh Regional Office _ 1628 Mail Service Center, Raleigh, NC 27699-1628 Physical Address: 3800 Barrett Drive, Raleigh, NC 27609 919-791-4200 PERMITTEE: Orange County PERMIT #: WQ0042650 PROJECT: Orange County Public Transportations Septic Improvements ISSUE DATE: August 27, 2021 This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of this permit until the Division has received this Certification and all required supporting documentation. It should be submitted in a manner that documents the Division’s receipt. Send the required documentation the Regional Supervisor, Water Quality Regional Operations Section at the address at the bottom. Any wastewater flow made tributary to the wastewater collection system extension prior to completion of this Certification shall be considered a violation of the permit and shall subject the Permittee to appropriate enforcement actions. The Permittee is responsible for tracking all partial certifications up until a final certification is received. A Final Certification shall be a complete set of record drawings and design calculations regardless of whether partials have been submitted. PERMITTEE’S CERTIFICATION I, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant to the applicable standards & requirements, the Professional Engineer below has provided applicable design/construction information to the Permittee, and the Permittee is prepared to operate & maintain the wastewater collection system permitted herein or portions thereof. Printed Name, Title Signature Date ENGINEER'S CERTIFICATION I, ________________________, as a duly registered Professional Engineer in the State of North Carolina, having been authorized to observe ( periodically, weekly, full time) the construction of the project name and location as referenced above for the above Permittee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the following construction: of approximately 1,200 linear feet of 8-inch gravity sewer; such that the construction was observed to be built within substantial compliance of this permit; 15A NCAC 02T; the Division of Water Resources’ Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division’s Minimum Design Criteria for the Fast-Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting materials. North Carolina Professional Engineer’s Seal w/signature & date: Final Partial (include description) Certification Comments/Qualifiers (attach if necessary): DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACTPRODUCERNAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY)(MM/DD/YYYY)INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT $OTHER: COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident) BODILY INJURY (Per person)$ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS $ UMBRELLA LIAB EACH OCCURRENCE $OCCUR EXCESS LIAB CLAIMS-MADE AGGREGATE $ $DED RETENTION $ PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED? (Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01) BBUDC-1 OP ID: KO 09/29/2020 Brian M. Jones First Insurance Services, Inc. P. O. Box 52409 Durham, NC 27717 Brian M. Jones 919-941-0549 919-941-0135 bjones448@nc.rr.com Builders Mutual Insurance Co 10844 BBUDC, Inc. PO Box 52552 Durham, NC 27717 A X 1,000,000 X Y CPP0080137 06/11/2020 06/11/2021 100,000 5,000 1,000,000 2,000,000 2,000,000 1,000,000 A X PCA0021837 05/10/2020 05/10/2021 X X XX 2,000,000 A MUB0008204 06/11/2020 06/11/2021 2,000,000 10,000X X A WCP1059059 05/10/2020 05/10/2021 1,000,000Y 1,000,000 1,000,000 A Rented/Leased CPP0080137 06/11/2020 06/11/2021 Rented 200,000 Equipment DEDUCTIBLE: 500.00 Leased Orange County North Carolina is included as additional insured under the General Liability,if required by a written/executed contract before a loss. ORANGE4 Orange County North Carolina 300 West Tryon Street PO Box 8181 Hillsborough, NC 27278 DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83 06/28/2021 Kim OConnorFirst Insurance Services, Inc. P.O Box 13687 Durham, NC 27709 919-941-0549 kimoc@firstins.net Builders Mutual Insurance Co 10844 BBUDC, Inc. PO Box 52552 Durham, NC 27717 A A A 10,000 A Orange County Asset Management Services 300 West Tryon Street Bldg B 3rd Floor Office 10 Hillsborough, NC 27278 CPP0080137 06/11/2021 06/11/2022 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 PCA0021837 06/11/2021 06/11/2022 1,000,000 MUB0008204 06/11/2021 06/11/2022 2,000,000 2,000,000 WCP1059059 06/11/2021 06/11/2022 1,000,000 1,000,000 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ PER OTH-STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DocuSign Envelope ID: 5B39D4BD-E0F1-4D92-A432-27FBE82D9C83