NCC200087_NOI Application_20200109

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/7/2020 4:39:13 PM (NCG01 NOI Submission)
Approve by Clark, Paul 1/8/2020 10:38:46 AM (Review- Construction NOI 20314)
• The task was assigned to Clark, Paul by round robin distribution 1/7/2020 4:39 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 9, 2020 5:00
PM 1/7/2020 4:39 PM
Submit by McCoy, Suzanne 1/9/2020 7:51:01 AM (Payment Verification for NCC200087)
* Aden R Stoltzfus
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/9/2020 7:50 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: February 19, 2020 5:00
PM 1 /8/2020 10:38 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name *
Everidge Subdivision
2. County*
Forsyth
3. Highway or Street
460 Everidge Road
Address *
Street narre only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code * 27103
7. Latitude * Enter the latitude in decimal degrees
36.0494
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-80.3114
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*
01/15/2020
Estimated Construction Project Start Date
10. Date to End*
06/06/2021
Estimated Construction Project End Cute
11. SIC (Primary) *
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial aassification for Developrrent
12. Acres to be
21.60
disturbed*
(including off -site borrow and waste areas)
13. Total site area 29.64
(acres) *
14. Post- 6.16
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-FORSY-2020-Everidge Subdivision
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 Salem Creek
Wate rbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-12-(4)
Index No. * NCWaterbody Index Minter
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
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 Hubbard Realty of Winston-Salem, Inc.
Name *
2. First Name* Bruce
If Corporation, enter Pegistered Agent First Barre
3. Last Name* Hubbard
If Corporation, enter Faegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address *
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 1598 Westbrook Plaza Drive
Address Line 2
Ste. 200
city
Winston-Salem
Fbstal / Zip Code
27103-1367
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
1598 Westbrook Plaza Drive
Address Line 2
Ste. 200
aty
Winston-Salem
Fbstal / Zip Code
27103-1367
State / Ftovince / Faegion
NC
Country
us
State / Frovince / Fbgion
NC
Country
us

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Keith
Contact - First
Name *
3. Primary Site
Nelson
Contact - Last
Name *
4. Title
Superintendant
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
[phone]
Telephone No.*
7. Organization
Shugart Homes
Name
8. Site Contact
Street Address
Mailing Address*
221 Jonestown Road
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27104
9. Consultant Name
(Optional)
Aden Stoltzfus
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
[phone]
Telephone No.
State / Rovince / Fbgion
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 01/07/2020
Approved *
2. E&SC Plan Project 338844
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth 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 Everidge Notice of Plan Approval-Winston-Salem.pdf 185.84KB
Approval Wst be RDFfornat
letter/documentation
6. NOI Certification NG01 Signed Certification Form.pdf 564.14KB
Form Mist be R7Ffon-rat
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 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 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
tra ` frl��t' e,
Type Name* Bruce R. Hubbard
Title President
Organization Hubbard Realty of Winston-Salem, Inc.
Date * 01 /07/2020

F. Tracking and COC Info
NOI Tracking No. 20314
NC Reference No. NCG01-2020-0087
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200087
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 87
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.)