NCC201343_NOI Application_20200403

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/30/2020 12:03:33 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 4/2/2020 3:14:52 PM (Review- Construction NOI 23774)
• McCoy, Suzanne reassigned the task to Farkas, Jim J 3/30/2020 1:48 PM
. The task was assigned to McCoy, Suzanne by round robin distribution 3/30/2020 12:04 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 1, 2020 5:00 PM
3/30/2020 12:04 PM
Submit by McCoy, Suzanne 4/3/2020 1:18:31 PM (Payment Verification for NCC201343)
* Victoria A Smith
• McCoy, Suzanne assigned the task to McCoy, Suzanne 4/3/2020 1:18 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 14, 2020 5:00 PM
4/2/2020 3:15 PM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* Bojangles' Restaurant
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street 2619 South Main Street
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* High Point
5. State * NC
6. Zip Code* 27263
7. Latitude* Enter the latitude in decimal degrees
35.9274
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.9856
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
Estirrated Construction Project Start Date
10. Date to End*
08/31/2020
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
1.25
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.25
(acres)*
14. Post- 1.00
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-GUILF-2020-Bojangles' Restaurant
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 Mile Branch
Wate rbody* Nacre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 17-7-3
Index No. * NC Waterbody 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 Bojangles' Restaurants, Inc
Name * If perrrittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* Claude
IF Corporation, enter F;bgistered Agent First Barre
3. Last Name* Clark
IF Corporation, enter Faegistered Agent Last Wre
3b. Title Sr. Director
4. Permitee E-mail [e-mail]
Address *
5. Permittee 704.940.8669
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 10009
Address Line 2
city
State / Frovince / Faegion
Greensboro
NC
Fbstal / Zip Code
Country
27404
USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
9432 Southern Pine Blvd
Address Line 2
City
State / Ffovince / Plegion
Charlotte
NC
Fbstal / Zip Code
Country
28273
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Claude
Contact - First
Name *
2. Primary Site
Clark
Contact - Last
Name *
3. Title
Sr. Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704.940.8669
Telephone No.
6. Organization
Bojangles' Restaurants, Inc
Name
7. Site Contact
Street Address
Mailing Address*
PO Box 10009
Address Line 2
city
Greensboro
Fbstal / Zip Code
27404
8. Consultant Name
(Optional)
Lee Bakely
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704.565.7071
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 03/24/2020
Approved *
2. E&SC Plan Project EN-20-0022
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of High Point
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 C-PRMT-High Point -Land Disturbance Permit Letter -
Approval letter or 1.86MB
2020-03-24. 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.
Re-sumittal
6. NOI Certification Bojangles-High Point _NCG01-eNO1-Certification-
Form 707KB
Form cc signed 03.25.20.pdf
Wst be FDFfornat
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 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
��lrrrr�f� ��lrr t�
Type Name* Claude Clark
Title Sr. Director
Organization Bojangles' Restaurants, Inc
Date * 03/30/2020

F. Tracking and COC Info
NOI Tracking No. 23774
NC Reference No. NCG01-2020-1343
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201343
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1343
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.)