NCC201027_NOI Application_20200323

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/16/2020 8:30:12 AM (NCG01 NOI Submission)
Approve by Clark, Paul 3/16/2020 10:55:08 AM (Review- Construction NOI 23089)
• The task was assigned to Clark, Paul by round robin distribution 3/16/2020 8:30 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 18, 2020 5:00
PM 3/16/2020 8:30 AM
Submit by McCoy, Suzanne 3/23/2020 3:42:09 PM (Payment Verification for NCC201027)
* City of Greensboro
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/23/2020 3:41 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 27, 2020 5:00 PM
3/16/2020 10:55 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Contract 2018-020A, Summit Avenue Streetscapes - Phase 2
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street Summit Avenue
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Greensboro
5. State * NC
6. Zip Code* 27401
7. Latitude* Enter the latitude in decinal degrees
36.0758
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-79.7883
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*
11/20/2020
Estirrated Construction Project Start Date
10. Date to End *
08/02/2021
Estinated Construction Project End Date
11. SIC (Primary) *
Highway (1611)
Standard Industrial C]assification for Development
12. Acres to be
1.65
disturbed*
(including off -site borrow and waste areas)
13. Total site area 3.02
(acres)*
14. Post- 2.72
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-GUILF-2020-Contract 2018-020A, Summit Avenue
Tracking ID Streetscapes - Phase 2
Assigned automatically
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 Muddy Creek
Waterbody* N3rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-11-14-1-3
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 City of Greensboro
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* John
It Corporation, enter Fbgistered Agent First Barre
3. Last Name* Fersner
If Corporation, enter Faegistered Agent Last %rre
3b. Title Chief Design Engineer
4. Permitee E-mail John. [e-mail]
Address *
5. Permittee 336-373-2302
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box3136
Address Line 2
300 West Washington Street
City State / Frovince / Faegion
Greensboro NC
Fostal / Zip Code Country
27402-3136 USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
300 West Washington Street
Address Line 2
City
State / Rovince / Plegion
Greensboro
NC
Fbstal / Zip Code
Country
27401
USA
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Melinda
Contact - First
Name *
2. Primary Site
King
Contact - Last
Name *
3. Title
Supervisor Construction Inspections
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-373-2372
Telephone No.
6. Organization
City of Greensboro
Name
7. Site Contact
Street Address
Mailing Address*
Post Office Box3136
Address Line 2
city
Greensboro
Fbstal / Zip Code
27402-3136
8. Consultant Name
(Optional)
First and Last nacre
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 03/05/2020
Approved *
2. E&SC Plan Project GUILF-2020-030
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
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 2018-
Approval letter or 525.24KB
020A Letter of Approval_with_Modifications.pdf
Grading Permit
Mast be RDFforrrat
Site Map (Optional) Helpful for linear project review
Mast be FDFform3t
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
Project limits are from SECU Boulevard (36.0778,-79.7850) to
Brenner Place (36.0749,-79.7889).
6. NOI Certification NCG01-eNO1-Certification-Form-2018-
Form 440.04KB
020A_SIGNED.pdf
Mast be RFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) 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 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 *
John D. Fersner, P.E.
Title
Chief Design Engineer
Organization
City of Greensboro
Date *
03/16/2020

F. Tracking and COC Info
NOI Tracking No. 23089
NC Reference No. NCG01-2020-1027
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201027
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1027
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.)