NCC201087_NOI Application_20200319

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/18/2020 2:39:03 PM (NCG01 NOI Submission)
Approve by Clark, Paul 3/18/2020 3:08:07 PM (Review- Construction NOI 23250)
• The task was assigned to Clark, Paul by round robin distribution 3/18/2020 2:39 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 20, 2020 5:00
PM 3/18/2020 2:39 PM
Submit by McCoy, Suzanne 3/19/2020 2:42:22 PM (Payment Verification for NCC201087)
* Athan Parker
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/19/2020 2:41 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 29, 2020 5:00 PM
3/18/2020 3:08 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* HAVEN
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Harnett
3. Highway or Street NC 27 W
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* BARBEQUE
5. State * NC
6. Zip Code* 27505
7. Latitude* Enter the latitude in decimal degrees
35.3371
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.0195
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*
05/01/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
12.24
disturbed*
(including off -site borrow and waste areas)
13. Total site area 62.73
(acres)*

14. Post- 15.05
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-HARNE-2020-HAVEN
Tracking ID Assignedautorraticaly
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 HANDY BRANCH
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 18-20-13-7-1
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional DRY BRANCH
Receiving Waterbody narre
Waterbody
15d. Waterbody 18-20-13-7
Index No. NCWaterbody Index Nurrber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index N nber
Index No.
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee 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 XCESSIVE RISK DEVELOPMENT, INC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* ATHAN
IF Corporation, enter Plegistered Agent First Barre
3. Last Name* PARKER
If Corporation, enter Faegistered Agent Last Wre
3b. Title VICE PRESIDENT
4. Permitee E-mail [e-mail]
Address* M
5. Permittee 919-795-9594
Telephone No.*
6. Permittee Mailing Street Address
Address* PO BOX4580
Address Line 2
City
State / Ftovince / Faegion
EMERALD ISLE
NC
Fbstal / Zip Code
Country
28594
USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
7401 ARCHERS CREEK CT
Address Line 2
City
State / Ffovince / Fbgion
EMERALD ISLE
NC
Flostal / Zip Code
Country
28594
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
FRoject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site ATHAN
Contact - First
Name *
2. Primary Site PARKER
Contact - Last
Name *
3. Title VICE PRESIDENT
4. Site Contact E- [e-mail]
mail Address* M
5. Site Contact 919-795-9594
Telephone No.*
6. Organization XCESSIVE RISK DEVELOPMENT, INC
Name
7. Site Contact Street Address
Mailing Address* PO BOX4580
Address Line 2
city
EMERALD ISLE
Fbstal / Zip Code
28594
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / Pegion
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................................................................................................__
1. Date E&SC Plan 03/09/2020
Approved *
2. E&SC Plan Project HARNE-2020-041
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Fayetteville (FRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan
Approval letter or
Grading Permit
Site Map (Optional)
EandSC.Approval.pdf
Mast be RDFfornat
Helpful for linear project review
Mast be FDFform3t
641.25KB
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
6. NOI Certification 2020.03.17.NOI.pdf 720.92KB
Form Mast be FDFformat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) 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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; 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 Artcle 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 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 * ATHAN PARKER
Title VICE PRESIDENT
Organization XCESSIVE RISK DEVELOPMENT, INC
Date * 03/18/2020

F. Tracking and COC Info
NOI Tracking No. 23250
NC Reference No. NCG01-2020-1087
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201087
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1087
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.)