NCC200748_NOI Application_20200225

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/24/2020 7:22:22 PM (NCG01 NOI Submission)
Approve by Clark, Paul 2/25/2020 8:29:48 AM (Review- Construction NOI 22374)
• The task was assigned to Clark, Paul by round robin distribution 2/24/2020 7:22 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 26, 2020 5:00
PM 2/24/2020 7:22 PM
Submit by McCoy, Suzanne 2/25/2020 1:25:32 PM (Payment Verification for NCC200748)
* BDG Architects
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/25/2020 1:25 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 7, 2020 5:00 PM
2/25/2020 8:29 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Fifth Third Bank
1 b. Specific Lot This field rray be used to list specffc lot numbers.
Numbers 1
2. County* Wake
3. Highway or Street 100 Capcom Avenue
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
35.9502
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.5293
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*
03/09/2020
Estimated Construction Project Start Date
10. Date to End *
09/30/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
0.75
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.05
(acres)*
14. Post- 0.67
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-WAKE-2020-Fifth Third Bank
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 Richland Creek
Waterbody* %neof waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-21-(1.5)
Index No. * NCWaterbody Index Narrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional Neuse
Receiving Waterbody narre
Waterbody
15d. Waterbody NCWaterbody Index Nurrber
Index No.
15e. Additional Waterbody name
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Nurrber
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. ^
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 Fifth Third Bank
Name *
2. First Name* Gloria
If Corporation, enter Pbegistered Agent First Barre
3. Last Name* Samuel
If Corporation, enter Faegistered Agent Last %rre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address *
5. Permittee 513-534-0993
Telephone No.*
6. Permittee Mailing Street Address
Address* 38 Fountain Square Plaza
Address Line 2
MD 10ATA1
City State / Frovince / Region
Cincinnati OH
Fostal / Zip Code Country
45202 USA
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
38 Fountain Square Plaza
Address Line 2
MD 10ATA1
City
State / Frovince / Fbgion
Cincinnati
OH
Fbstal / Zip Code
Country
45202
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Clay
Contact - First
Name *
2. Primary Site
Hoskins
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-562-9974
Telephone No.
6. Organization
Vericon Construction
Name
7. Site Contact
Street Address
Mailing Address*
13504-J South Point Boulevard
Address Line 2
city
Charlotte
Fbstal / Zip Code
28273
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/30/2019
Approved *
2. E&SC Plan Project 2019-00002522
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Wake Forest
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 Fifth Third Bank Capcom Letter of Approval.pdf 90.05KB
Approval Wst be FDFfornat
letter/documentation
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
The original NOI certification form and the $100.00 fee was mailed
via UPS to the address on the form and confirmed delivered on
Thursday 02/20/20 at 10:23am
(Tracking #1ZE8403X0199176672).
6. NOI Certification NCGO1 NOI Certification Form-Signed.pdf 286.66KB
Form Mast be Ft7Ffon-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
��otr� ��rrrrrrr°/
Type Name* Gloria Samuel
Title Vice President
Organization Fifth Third Bank
Date * 02/24/2020

F. Tracking and COC Info
NOI Tracking No. 22374
NC Reference No. NCG01-2020-0748
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200748
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 748
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.)