NCC200869_NOI Application_20200311

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/3/2020 9:31:15 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 3/4/2020 7:17:20 AM (Review- Construction NOI 22673)
. The task was assigned to McCoy, Suzanne by round robin distribution 3/3/2020 9:32 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 5, 2020 5:00 PM
3/3/2020 9:32 AM
Submit by McCoy, Suzanne 3/11/2020 12:32:28 PM (Payment Verification for NCC200869)
* Raleigh Custom Home
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/11/2020 12:31 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 15, 2020 5:00 PM
3/4/2020 7:17 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name *
1417 Sky Vista
1 b. Specific Lot
This field rray be used to list specffc lot numbers.
Numbers
Lot 30 Southern Hills
2. County*
Wake
3. Highway or Street 1417 Sky Vista Way
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Raleigh
5. State * NC
6. Zip Code* 27615
7. Latitude* Enter the latitude in decimal degrees
35.9580
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.6897
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*
03/30/2020
Estimated Construction Project Start Date
10. Date to End *
09/30/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single
Family Houses (SFE)
(1521)
Standard Industrial Classification for Development
12. Acres to be
0.48
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.07
(acres)*

14. Post- 0.25
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-1417 Sky Vista
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 Upper Barton Creek
Waterbody* %rm of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-15-(1)
Index No.* NCWaterbody Index Nunber
Stormwater V 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. ^
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 Raleigh Custom Homes Inc.
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Kyle
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Johnson
If Corporation, enter Faegistered Agent Last Wre
3b. Title Operations Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 9185300197
Telephone No.*
6. Permittee Mailing Street Address
Address* 6736 Falls of Neuse Road
Address Line 2
city State / Frovince / Region
Raleigh NC
Fbstal / Zip Code Country
27615-5300 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
6736 Falls of Neuse Road
Address Line 2
City
State / Ffovince / i egion
Raleigh
NC
Flostal / Zip Code
Country
27615-5300
us
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Project Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Kyle
Contact - First
Name *
2. Primary Site Johnson
Contact - Last
Name *
3. Title
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 9185300197
Telephone No.*
6. Organization Raleigh Custom Homes Inc.
Name
7. Site Contact Street Address
Mailing Address* 6736 Falls of Neuse Rd. Suite 300
Address Line 2
city
Raleigh
Postal / Zip Code
27615
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 / Province / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
............................................................................................................................................................................................................................................................................................................................__
1. Date E&SC Plan 03/02/2020
Approved *
2. E&SC Plan Project SEC-031311-2020
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan Approval- 291.52KB
Approval letter or S&E_SingleLot_PlanReviewChecklist_Septic (3).pdf
Grading Permit
Mast be Ft7Ffon-rat
Site Map (Optional) Helpful for linear project review
Southern Hills 30 PLOT PLAN REV 3 (2).pdf 171.78KB
Mast be RDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
Approval letter and plot plan for reference.
6. NOI Certification 1417 Sky Vista COI.pdf 183.6KB
Form Wst be RDF formal
This is an Express r 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
Type Name* Timothy Thompson
Title President
Organization Raleigh Custom Homes Inc.
Date * 03/03/2020

F. Tracking and COC Info
NOI Tracking No. 22673
NC Reference No. NCG01-2020-0869
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200869
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 869
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.)