NCC201173_NOI Application_20200325

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/23/2020 9:24:54 AM (NCG01 NOI Submission)
Approve by Clark, Paul 3/23/2020 9:38:44 AM (Review- Construction NOI 23358)
• The task was assigned to Clark, Paul by round robin distribution 3/23/2020 9:25 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 25, 2020 5:00
PM 3/23/2020 9:25 AM
Submit by McCoy, Suzanne 3/25/2020 8:05:47 AM (Payment Verification for NCC201173)
* Janie Murray
• McCoy, Suzanne assigned the task to McCoy, Suzanne 3/25/2020 8:05 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 4, 2020 5:00 PM
3/23/2020 9:38 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* Amelia Point
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Johnston
3. Highway or Street Shotwell Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Clayton
5. State * NC
6. Zip Code* 27520
7. Latitude* Enter the latitude in decimal degrees
35.6509
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.4837
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*
04/06/2020
Estimated Construction Project Start late
10. Date to End *
09/14/2020
Estimated Construction Project End late
11. SIC (Primary)*
Commercial (1542)
Standard Industrial cassification for Development
12. Acres to be
2.10
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.10
(acres)*
14. Post- 0.98
construction (Estimated)
impervious area
(acres) *

NCC Project NCC-JOHNS-2020-Amelia Point
Tracking ID Assignedautonatically
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 Little Creek
Wate rbody* f\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-43-12
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 Cloudbreak Investments, LLC
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Nathan
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Evans
IF Corporation, enter Faegistered Agent Last Wre
3b. Title manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-345-6729
Telephone No.*
6. Permittee Mailing Street Address
Address* 507 Peace Street Suite 101
Address Line 2
City State / Frovince / Region
Raleigh NC
Fbstal / Zip Code Country
27603 Wake
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
507 Peace Street Suite 101
Address Line 2
City
State / Ffovince / Fbgion
Raleigh
NC
Flostal / Zip Code
Country
27603
Wake
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Nathan
Contact - First
Name *
2. Primary Site
Evans
Contact - Last
Name *
3. Title
Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-345-6729
Telephone No.
6. Organization
Cloudbreak Investments, LLC
Name
7. Site Contact
Street Address
Mailing Address*
507 Peace Street Suite 101
Address Line 2
city
Raleigh
Fbstal / Zip Code
27603
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
Wake

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/20/2020
Approved *
2. E&SC Plan Project JC#19-143-P
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston 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 19-143 Amelia Point ESC appr 3.20.2020.pdf 94.81 KB
Approval letter or Mast beRDFforml
Grading Permit
Site Map (Optional) Helpful for linear project review
Mast be R7Fform3t
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.
6. NOI Certification signed eNO1 form.pdf 298.37KB
Form Mast be FDFformat
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
IT 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* Nathan Evans
Title Manager
Organization Cloudbreak Investments, LLC
Date * 03/23/2020

F. Tracking and COC Info
NOI Tracking No. 23358
NC Reference No. NCG01-2020-1173
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201173
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1173
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.)