NCC202268_NOI Application_20200601

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/27/2020 6:47:12 PM (NCG01 NOI Submission)
Approve by Farkas, Jim J 5/29/2020 2:59:29 PM (Review- Construction NOI 26256)
• The task was assigned to Farkas, Jim J by round robin distribution 5/27/2020 6:47 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 29, 2020 5:00 PM
5/27/2020 6:47 PM
Submit by McCoy, Suzanne 6/1/2020 7:54:16 AM (Payment Verification for NCC202268)
* Russell Hart
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/1/2020 7:53 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 10, 2020 5:00 PM
5/29/2020 2:59 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 * Orchard Meadows Lot 10
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers 10
2. County* Wake
3. Highway or Street 2808 Orchard Meadows Ct.
Address* Street narre only is acceptable if no address number assigned yet
4.City orTownship* Raleigh
5. State * NC
6. Zip Code * 27606
7. Latitude* Enter the latitude in decimal degrees
35.7025
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-78.7405
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*
06/15/2020
Estimated Construction Project Start Date
10. Date to End *
06/14/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial Classification for Developrrent
12. Acres to be
0.34
disturbed*
(including off -site borrow and waste areas)
13. Total site area 0.92
(acres) *

14. Post- 0.14
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-Orchard Meadows Lot 10
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 Dutchmans Branch
Waterbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 27-43-4.5
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
Legally Pesponsible Entity
Name *
Cypress Homes Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Russell
IF Corporation, enter Faegistered Agent First Wre
3. Last Name*
Hart
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9197626556
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box824
Address Line 2
City
State / Province / Pbegion
Fuquay Varina
NC
Postal / Zip Code
Country
27526
USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
205 Sherman Pines Drive
Address Line 2
city
State / Province / Region
Fuquay-Varina
NC
Postal / Zip Code
Country
27526
US
8. Type of
Individual
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Russell
Contact - First
Name *
2. Primary Site
Hart
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9197626556
Telephone No.
6. Organization
Cypress Homes Inc.
Name
7. Site Contact
Street Address
Mailing Address*
PO Box824
Address Line 2
city
Fuquay Varina
Postal / Zip Code
27526
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 / Province / Region
NC
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/20/2020
Approved *
2. E&SC Plan Project SEC-036911-2020
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
SEC-036911-2020_Approval-
Approval letter or
S&EConstructionPlan ReviewChecklist-V.2 WM 5- 272.01KB
Grading Permit
20-20.pdf
Mast be RFfornat
6. Site Location Map
Helpful for linear project review
(Optional)
Wst 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
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
995.17KB
SW_(052720).pdf
Mast be FDFfornat
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
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* Russell Hart
Title President
Organization Legally Iesponsible Entity
Cypress Homes Inc.
Date * 05/27/2020

F. Tracking and COC Info
NOI Tracking No. 26256
NC Reference No. NCG01-2020-2268
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202268
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2268
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.)