NCC203033_NOI Application_20200717

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/15/2020 5:15:33 PM(NCG01 NOI Submission)
Approve by Clark, Paul 7/16/2020 11:01:48 AM(Review-Construction NOI 28349)
• The task was assigned to Clark, Paul by round robin distribution 7/15/2020 5:16 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 17,2020 5:00 PM
7/15/2020 5:16 PM
Submit by Selkane,Aziza 7/17/2020 9:09:07 AM(Payment Verification for NCC203033)
* Jay T Oglesby
• Selkane,Aziza assigned the task to Selkane,Aziza 7/17/2020 9:08 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:August 27, 2020 5:00 PM
7/16/2020 11:02 AM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIVWATER DISCHARGES associated with construction acti\Aties(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting f•No
an NOI that was r Yes
rejected before?
1a. Project Name* The Gallery at Royal Park
1 b.Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2.County* Mecklenburg
3. Highway or Street 4101 Glenloch Circle
Address* Street nacre only is acceptable if no address number assigned yet
4.City or Townsh i p* Matthews
5.State* NC
6.Zip Code* 28105
7. Latitude* Enter the latitude in decimal degrees
35.1146
8. Longitude* Enter the longitude in decimal degrees(M.JST be negative)
-80.6919
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* 07/20/2020
Estimated Construction Project Start Date
10. Date to End* 07/01/2022
Estimated Construction Project End Date
11.SIC(Primary)* Residential, Other than SFE(1522)
Standard Industrial aassification for Development
12.Acres to be 18.68
disturbed* (including off-site borrow and waste areas)
13.Total site area 35.99
(acres)*

14. Post- 6.83
construction (Estirrated)
impervious area
(acres)*
NCC Project NCC-MECKL-2020-The Gallery at Royal Park
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 North Fork Crooked Creek
Waterbody* %rre of waterbody into which stornwater runoff will discharge
15b.Waterbody 13-17-20-1
Index No.* NCWaterbody Index Number
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. ^
Fl rnittee 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 Responsible Entity
Name* Liberty Healthcare Properties of North Carolina, LLC
It pernittee is an individual(i.e.,organization does not apply),enter first and last narre in this field.
2. First Name* William
If Corporation,enter Faegistered Agent First%rre
3. Last Name* Purvis
It Corporation,enter Fbgistered Agent Last Iona
3b.Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-592-5400
Telephone No.*
6. Permittee Mailing Street Address
Address* 2334 S 41st Street
Address Line 2
City State/Rovince/F;bgion
Wilmington NC
Fbstal/Zip Code Country
28403 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 2334 S 41st Street
Address Line 2
City State/Frovince/Region
Wilmington NC
Fbstal/Zip Code Country
28403 us
8.Type of Non-Government
Ownership*

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Calan
Contact-First
Name*
2. Primary Site Hollingsworth
Contact-Last
Name*
3.Title Project Manager
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact 205-234-9207
Telephone No.*
6.Organization CBI Construction Services
Name
7.Site Contact Street Address
Mailing Address* 431 Office Park Drive
Address Line 2
City State/Rovince/Region
Birmingham AL
Fbstal/Zip Code Country
35223-2411 us
8. Consultant Name (Optional)
Kevin Gorman
First and Last narre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 7045219880
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/13/2020
Approved*
2. E&SC Plan Project 401860
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Mecklenburg 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 PCO5 approval#401860.pdf 54.98KB
Approval letter or Mast beRDFforml
Grading Permit
6.Site Location Map Helpful for linear project review
(Optional) Quad Map.pdf 2.27MB
Mast be RDFfornat.Rease do not upload entire set of E&SCplans.
7. Notes(Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.Include additional waterbodies for linear projects if necessary.
8. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 701.52KB
SW(002).pdf
Mast be R7Ffornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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
j���lf•r.��r�t/rrfr.•rif
Type Name* William B Purvis
Title Manager
Organization Legally Ibsponsible Entity
Liberty Healthcare Properties of North Carolina, LLC
Date* 07/15/2020

F. Tracking and COC Info
NOI Tracking No. 28349
NC Reference No. NCG01-2020-3033
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC203033
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 3033
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)
Initial Invoice No. NCC203033-2020
Invoice Due Date 8/15/2020
Initial Fee $ 100.00
Invoice Status OPEN