NCC201950_NOI Application_20200512

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/11/2020 2:33:02 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 5/11/2020 3:46:32 PM (Review- Construction NOI 25425)
. The task was assigned to Garcia, Lauren V by round robin distribution 5/11/2020 2:33 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 13, 2020 5:00 PM.
The priority is: High 5/11/2020 2:33 PM
Submit by McCoy, Suzanne 5/12/2020 7:37:45 AM (Payment Verification for NCC201950)
* Roebuck Design Build LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 5/12/2020 7:37 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 22, 2020 5:00 PM.
The priority is: High 5/11/2020 3:46 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name *
Miravalle lot 5
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
Miravalle 5
6225 Old Miravalle Court
2. County*
Wake
3. Highway or Street 6225 Old Miravalle Court
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Raleigh
5. State * NC
6. Zip Code * 27614
7. Latitude * Enter the latitude in decimal degrees
35.9526
8. Longitude* Enter the longitude in decir al degrees (MJST be negative)
-78.6730
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*
05/14/2020
Estimated Construction Project Start Date
10. Date to End*
02/19/2021
Estinated Construction Project End Cute
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrrent
12. Acres to be
0.94
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.48
(acres) *

14. Post- 0.14
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Mi rava Ile lot 5
Tracking ID Assignedautorraticaly
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 * %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-15-(2)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Falls Lake
Receiving Waterbody narre
Waterbody
15d. Waterbody 27-(5.5)
Index No. NCWaterbody Index Nurrber
15e. Additional Neuse River
Receiving Waterbody narre
Waterbody
15f. Waterbody 27-(20.7)
Index No. NCWaterbody Index Nurrber
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
Legally Pesponsible Entity
Name *
Robuck Design Build LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Gerri
If Corporation, enter Faegistered Agent First %rre
3. Last Name*
Herakovich
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Member Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-422-2858
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 17102
Address Line 2
City State / Rovince / Pbegion
Raleigh NC
Fbstal / Zip Code Country
27619 United States
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
6131 Falls of Neuse Road
Address Line 2
Suite 201
City
State / Ftovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27609-3518
US
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Gerri
Contact - First
Name *
2. Primary Site
Herakovich
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-422-2858
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
6131 Falls of Neuse Road
Address Line 2
Suite 201
city
Raleigh
Fbstal / Zip Code
27609-3518
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
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/11/2020
Approved *
2. E&SC Plan Project SEC-036824-2020
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 -
Approval letter or
S&E_SingleLot_PlanReviewChecklist_Conditonal 280.14KB
Grading Permit
Approva Miravalle lot 5 20200511.pdf
Mast be RFforml
6. Site Location Map
Helpful for linear project review
(Optional)
Mast be FDFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional)
Ffovide 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.
8. NOI Certification
MV5 NOI Certificaiton Form 051120.pdf 256.59KB
Form
Mast be R7Ffon-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 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
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
��tfii � cp,�v�drlr
Type Name* Gerri R. Herakovich
Title Member Manager
Organization Legally Ibsponsible Entity
Robuck Design Build LLC
Date * 05/11 /2020

F. Tracking and COC Info
NOI Tracking No. 25425
NC Reference No. NCG01-2020-1950
Uses 'count number' variable (incremrented by SP)
Certificate of NCC201950
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 1950
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.)