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HomeMy WebLinkAboutNCC223599_NOI Application_20221026Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 10/18/2022 4:40:52 PM (NCG01 NOI Submission) Approve by Broussard, Brooklyn C 10/19/2022 7:14:10 AM (Review - NOI 109594 Contract 2018-048, Greene Street Streetscape) • The task was assigned to Broussard, Brooklyn C by round robin distribution 10/18/2022 4:41 PM • The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 21, 2022 5:00 PM 10/18/2022 4:41 PM by Workflow 10/19/2022 7:14:18 AM (Workflow Start Event) Submit by Holloman, Tevye L 10/26/2022 11:56:30 AM (Payment Verification for NCC223599) F City of Greensboro • Holloman, Tevye L assigned the task to Holloman, Tevye L 10/26/2022 11:55 AM The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 30, 2022 5:00 PM 10/19/2022 7:14 AM �a NORTH CAROLINA, Enri--tn! C2-1;ly A. Project Information Part A. Project Location and Waterbody Information Are you submitting No an NOI that was • Yes rejected before? Previous Rejected 109174 NOI No. Prior Reviewer Name Brooklyn Broussard la. Project Name* Contract 2018-048, Greene Street Streetscape 1 b. Specific Lot This field may be used to list specifc lot numbers. Numbers 1 c. Parcel ID List all PINs associated with this project. Number(s) (PIN) 0000632, 0000244, 0000597, 0000596, 0000616 and existing street right of way. 2. County* Guilford 3. Highway or Street North Greene Street Address* Street name only is acceptable if no address number assigned yet 4. City or Township* Greensboro 5. State* NC 6. Zip Code* 27401 7. Latitude* Enter the latitude in decimal degrees 36.0727 8. Longitude* Enter the longitude in decimal degrees (MUST be negative) -79.7915 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* 01/16/2023 Estimated Construction Project Start Date 10. Date to End* 09/29/2023 Estimated Construction Project End Date 11. SIC (Primary)* Highway (1611) Standard Industrial Classification for Development 12. Acres to be 4.00 disturbed* (including off -site borrow and waste areas) 13. Total site area 4.00 (acres) * 14. Post -construction 3.95 impervious area (Estimated) (acres)* Project Tracking ID NCC-GUILF-2023-Contract 2018-048, Greene Street Streetscape Assigned automatically (not used) 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 Muddy Creek Waterbody * Name of waterbody into which stormwater runoff will discharge 15b. Waterbody Index 16-11-14-1-3 No. * NC Waterbody Index Number Stormwater No discharges will flow Yes to additional waters* 15c. Additional North Buffalo Creek Receiving Waterbody Waterbody name 15d. Waterbody Index 16-11-14-1 No. NC Waterbody Index Number 15e. Additional Waterbody name Receiving Waterbody 15f. Waterbody Index NC Waterbody Index Number No. 16a. Is this project Yes subject to the NC No, not subject to NC SPCA Sediment Pollution Control Act?* B. Permittee Information Part B. Permittee Information - Legally Responsible Entity and Individual ........................................................................................................................................................................ Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application form must 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of that permit. 1. Permittee* Legally Responsible Entity City of Greensboro If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name. Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC SPCA Financial Responsibility/Ownership (FRO) Form. 2. First Name* John If Corporation, enter Registered Agent First Name 3. Last Name* Fersner If Corporation, enter Registered Agent Last Name 3b. Title Chief Design Engineer 4. Permitee E-mail John.Fersner@greensboro-nc.gov Address* 5. Permittee 336-373-2302 Telephone No.* 6. Permittee Mailing Street Address Address* Post Office Box 3136 Address Line 2 City State / Province / Region Greensboro NC Postal / Zip Code Country 27402-3136 USA Check box if the Yes street address the same as mailing address 7. Permittee Street Street Address Address* 300 West Washington Street Address Line 2 City State / Province / Region Greensboro NC Postal / Zip Code Country 27401 USA 8. Type of Ownership is only individual if an individual is named in B.1. above. Ownership* Government - Municipal C. Site Contact Information Part C. Project Site Contact Information ................................................................................................................................................................................................................................................................................................................................................................................................. 1. Primary Site Jason Contact - First Name* 2. Primary Site Geary Contact - Last Name* 3. Title City Engineer 4. Site Contact E-mail Jason.Geary@greensboro-nc.gov Address* 5. Site Contact 336-373-2302 Telephone No.* 6. Organization Name City of Greensboro 7. Site Contact Mailing Address* 8. Consultant Name Street Address Post Office Box 3136 Address Line 2 City Greensboro Postal / Zip Code 27402-3136 (Optional) First and Last name 9. Consultant E-mail This person will be copied on all correspondence. 10. Consultant Telephone No. 11. Billing E-mail (For Annual Fee correspondence) Guy.ingle@greensboro-nc.gov Default is legally responsible person e-mail 12. Billing Telephone (For Annual Fee correspondence) 336-373-2302 Default is legally responsible person telephone State / Province / Region NC Country USA D. E&SC Plan Part D. Erosion & Sediment Control (E&SC) Plan Approval Information 1. Date E&SC Plan 10/05/2022 Approved * 2. E&SC Plan Project GUILF-2022-010 Number/ID* Assigned by agency or local program 3. E&SC Plan State DEQ Office Approved by* Local Program 4. State DEQ Office* Winston-Salem (WSRO) Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can include the beginning point and end point coordinates in the "Notes" box below). 5. E&SC Plan 2018-048 Letter of Approval (GUILF-2022-010).pdf 1.34MB Approval letter or Must be PDF format Grading Permit 6. Signed FRO Financial Responsibility/Ownership Form 2018-048 FRO Form-Signed.pdf 638.85KB Must be PDF format 7. Site Location Map Must be PDF format (limit 20 MB) 2018-048_VicinityMap.pdf 84.75KB Please do not upload entire set of E&SC plans. 8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents support the application. Include additional waterbodies if necessary. 9. NOI Certification 2018-048 NCG01 NOI Certification Form.pdf 800.94KB Form Must be PDF format This is an Express • No Review Project* Yes E. Certification 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). Under penalty of law, I certify that: * 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. * 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. * I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. * 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:* The Legally Responsible Person named on this Notice of Intent Authorized Responsible Person' (signing on behalf of Legally Responsible Person named in Part B) 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* John D. Fersner, PE Title Chief Design Engineer Organization Legally Responsible Entity City of Greensboro Date * 10/18/2022 F. Tracking and COC Info NOI Tracking No. 109594 NC Reference No. NCG01-2022-3599 Indicates NCG01 or NCG25. Uses NOI number until approved, then uses NUMBER incremented by SP (passed from workflow if eNOI approved) Certificate of NCC223599 Coverage (COC) No.* Uses NOI number until approved, then uses NUMBER incremented by SIP (formatted and passed from workflow if eNOI approved) Initial Invoice No. NCC223599-2022 Invoice Due Date 11/18/2022 Initial Fee $ 100.00 Invoice Status OPEN