NCC200732_NOI Application_20200225

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/24/2020 10:20:37 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/24/2020 11:25:46 AM (Review- Construction NOI 22307)
• The task was assigned to Clark, Paul by round robin distribution 2/24/2020 10:20 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 26, 2020 5:00
PM 2/24/2020 10:20 AM
Submit by McCoy, Suzanne 2/25/2020 10:17:09 AM (Payment Verification for NCC200732)
* Christopher Schiavone
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/25/2020 10:16 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 6, 2020 5:00 PM
2/24/2020 11:25 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Prescott Subdivision Lot 22
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Wake
3. Highway or Street 5537 Old Pearce Rd
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Wake Forest
5. State * NC
6. Zip Code* 27587
7. Latitude* Enter the latitude in decimal degrees
35.9590
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.4519
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*
02/21/2020
Estimated Construction Project Start Date
10. Date to End*
10/31/2020
Estimated Construction Project End Date
11. SIC (Primary) *
Residential, Other
than SFE (1522)
Standard Industrial C]assification for Development
12. Acres to be
0.70
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.18
(acres) *
14. Post- 0.10
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-WAKE-2020-Prescott Subdivision Lot 22
Tracking ID Assigned autorratically
Belowyou 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
Wate rbody* Nacre of waterbody into which storm ater runoff will discharge
15b. Waterbody 27-57-2
Index No. * NCWaterbody Index Nurrber
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. ^
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 Gemstone Homes LLC
Name *
2. First Name* Chris
IF Corporation, enter Pegistered Agent First Barre
3. Last Name* Schiavone
If Corporation, enter Faegistered Agent Last %rre
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
Fbstal / Zip Code
27540
Check box if the rJ Yes
street address the
same as mailing
address
State / Frovince / Faegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
PO Box 146
Address Line 2
City
State / Frovince / Fbgion
Holly Springs
NC
Fbstal / Zip Code
Country
27540
USA
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Ken
Contact - First
Name *
2. Primary Site Godwin
Contact - Last
Name *
3. Title VP Construction
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 919-697-2370
Telephone No.*
6. Organization Gemstone Homes
Name
7. Site Contact Street Address
Mailing Address* PO Box 146
Address Line 2
City
Holly Springs
Fbstal / Zip Code
27540
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 / Fegion
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 02/19/2020
Approved *
2. E&SC Plan Project SEC-030781-2019
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. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan Lot 22 Prescott _ Land Distrubance Application -
Approval 262.45KB
APPROVED 2.21.20.pdf
letter/documentation
Mast be R7Fforrrat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification Lot 22 PR _ NCG01_ 2.21.20.pdf 345.2KB
Form Mast be FDFfon-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 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
tlrl u j�c��b�.•r�
Type Name* Chris Schiavone
Title President
Organization Gemstone Homes LLC
Date * 02/24/2020

F. Tracking and COC Info
NOI Tracking No. 22307
NC Reference No. NCG01-2020-0732
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200732
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 732
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.)