NCC200475_NOI Application_20200207

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/5/2020 9:43:41 PM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 2/6/2020 7:35:57 AM (Review- Construction NOI 21588)
• The task was assigned to McCoy, Suzanne by round robin distribution 2/5/2020 9:44 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 7, 2020 5:00
PM 2/5/2020 9:44 PM
Submit by McCoy, Suzanne 2/7/2020 7:18:35 AM (Payment Verification for NCC200475)
* Daniel W. Prichett
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/7/2020 7:17 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 19, 2020 5:00 PM
2/6/2020 7:36 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Nido & Mariana Qubein Children's Museum
2. County* Guilford
3. Highway or Street 200 Montlieu Avenue
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* High Point
5. State * NC
6. Zip Code * 27262
7. Latitude * Enter the latitude in decirral degrees
35.9662
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.0102
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
02/17/2020
Estimated Construction Project Start Cate
10. Date to End*
10/05/2020
Estimated Construction Project End Cute
11. SIC (Primary)*
Other (0000)
Standard Industrial Classification for Ceveloprrent
12. Acres to be
2.50
disturbed*
(including off -site borrow and waste areas)
13. Total site area
2.54
(acres) *
14. Post-
1.63
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-GUILF-2020-Nido & Mariana Qubein Children's Museum
Tracking ID
Assigned autorratically

Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Boulding Branch
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 17-3-2
Index No.* NCWaterbody Index Ninber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fternittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Nido & Mariana Qubein Children's Museum, Inc.
Name *
2. First Name* Barry
IF Corporation, enter Pbegistered Agent First Barre
3. Last Name * Kitley
If Corporation, enter Faegistered Agent Last %rre
3b. Title Chairman
4. Permitee E-mail [e-mail]
Address *
5. Permittee 336-841-9363
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1030
Address Line 2
city
High Point
Fbstal / Zip Code
27261
Check box if the r Yes
street address the
same as mailing
address
State / Frovince / Faegion
NC
Country
us
7. Permittee Street
Street Address
Address*
508 North Hamilton Street
Address Line 2
City
State / Frovince / Fbgion
High Point
NC
Fbstal / Zip Code
Country
27262-4057
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site
Barry
Contact - First
Name *
2. Primary Site
Kitley
Contact - Last
Name *
3. Title
Chairman
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-841-9363
Telephone No.*
6. Organization
Nido & Mariana Qubein Children's Museum
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 1030
Address Line 2
city
State / Rovince / Region
High Point
NC
Fbstal / Zip Code
Country
27261
us
8. Consultant Name
(Optional)
Daniel W Pritchett
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-886-5523
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/04/2020
Approved *
2. E&SC Plan Project EN1903712292
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of High Point
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan LOA EN1903712292 2-4-2020.pdf 3.88MB
Approval Wst be FDFfornat
letter/documentation
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NOI Certification Form signed 02.05.2020.pdf 461.27KB
Form Mast be FDFformat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Responsible Person named on this Notice of Intent
f Authorized Responsible Person*
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
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 NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name* Barry Kitley
Title Chairman
Organization Nido and Mariana Qubein Children's Museum, Inc.
Date * 02/05/2020

F. Tracking and COC Info
NOI Tracking No. 21588
NC Reference No. NCG01-2020-0475
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200475
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 475
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)