NCC192007_NOI Application_20190924

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/20/2019 9:18:18 AM (NCG01 NOI Submission)
Approve by Lucas, Annette 9/23/2019 9:55:33 AM (Review- Construction NOI 16117)
• Georgoulias, Bethany reassigned the task to Lucas, Annette 9/20/2019 9:30 AM
In A - / didn't put you back on the team, but 1 am reassigning some of Alaina's tasks through today to
clear her for the enforcement work. 1 picked up 5 or 6 that came in for her yesterday. Thanks for
helping out!
• The task was assigned to Morman, Alaina by round robin distribution 9/20/2019 9:18 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 24, 2019 5:00
PM 9/20/2019 9:18 AM
Submit by McCoy, Suzanne 9/24/2019 9:08:59 AM (Payment Verification for NCC192007)
p Christopher Schiavone.
McCoy, Suzanne assigned the task to McCoy, Suzanne 9/24/2019 9:08 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 4, 2019 5:00
PM 9/23/2019 9:55 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Perry Farms Lots 15, 17, 71
2. County* Wake
3. Highway or Street 1429 Sweetclover Dr
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Wake Forest
5. State * NC
1r-i)iTII1T7i)MfiTif_T1IIa10141
6. Zip Code* 27587
7. Latitude * Enter the latitude in decirral degrees
35.9536
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.4606
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*
09/18/2019
Estimated Construction Project Start Date
10. Date to End*
07/31 /2020
Estimated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Development
12. Acres to be
0.52
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.05
(acres)*
14. Post- 0.08
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-WAKE-2019-Perry Farms Lots 15, 17, 71
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 Perry Creek
Waterbody* Narre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-57-2
Index No. * NCWaterbody Index Nurrber
Stormwater fJ 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.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
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 Gemstone Homes LLC
Name *
2. First Name* Chris
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Schiavone
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-355-6549
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 146
Address Line 2
City
Holly Springs
Postal / Zip Code
27540
Check box if the r% Yes
street address the
same as mailing
address
State / Province / Region
NC
Country
us
7. Permittee Street Street Address
Address* PO Box 146
Address Line 2
City
State / Province / Region
Holly Springs
NC
Fbstal / Zip Code
Country
27540
us

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Ken
Contact - First
Name *
3. Primary Site Godwin
Contact - Last
Name *
4. Title Superintendent
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 919-697-2370
Telephone No.*
7. Organization Gemstone Homes
Name
8. Site Contact Street Address
Mailing Address* PO Box 146
Address Line 2
city
Holly Springs
R>stal / Zip Code
27540
9. Consultant Name (optional)
First and Last nave
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 09/09/2019
Approved *
2. E&SC Plan Project SEC-023216-2019
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Wake County
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 SEC-023216-2019_Approval.pdf 298.79KB
Approval Mast be FDFfornat
letter/documentation
6. NOI Certification NCG01 - Perry Farms Lots 15,17,71.pdf 344.64KB
Form Mist be RDFfornet
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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
r 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
�`��tuT uj'�c��b�.•r�
Type Name* Chris Schiavone
Title President
Organization Gemstone Homes LLC
Date * 09/20/2019

F. Tracking and COC Info
NOI Tracking No. 16117
NC Reference No. NCG01-2019-2007
Uses 'count number variable (incremrented by SP)
Certificate of NCC192007
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2007
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)