NCC203564_NOI Application_20200818

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/14/2020 11:38:01 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 8/17/2020 8:23:41 AM (Review- Construction NOI 29926)
• The task was assigned to Garcia, Lauren V by round robin distribution 8/14/2020 11:38 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 18, 2020 5:00
PM 8/14/2020 11:38 AM
Submit by McCoy, Suzanne 8/18/2020 8:26:12 AM (Payment Verification for NCC203564)
* David 8 Washburn
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/18/2020 8:25 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 28, 2020 5:00
PM 8/17/2020 8:23 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 29860
NOI No.
Prior Reviewer Matt Gwinn
Name
1a. Project Name * WASHBURN BUILDING CONTRACTORS, INC
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Rutherford
3. Highway or Street OFF UNION & JJ GUFFEY RIDS
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* RUTHERFORDTON
5. State * NC
6. Zip Code * 28115
7. Latitude * Enter the latitude in decimal degrees
35.3450
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-81.9890
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* 08/21/2020
Estimated Construction Project Start Date
10. Date to End* 08/20/2023
Estimated Construction Project End Date
11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Developrrent

12. Acres to be 0.60
disturbed* (including off -site borrow and waste areas)
13. Total site area 0.60
(acres) *
14. Post- 0.20
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-RUTHE-2020-WASHBURN BUILDING CONTRACTORS, INC
Tracking ID Assigned automatically
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 MOUNTAIN CREEK
Waterbody * %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 9-25-(3.5)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs *
15c. Additional BROAD RIVER
Receiving Waterbody name
Waterbody
15d. Waterbody 9-(25.5)
Index No. NCWaterbody Index Nunber
15e. Additional Waterbody nacre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index Number
Index No.
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 Responsible Entity
Name * WASHBURN BUILDING CONTRACTORS, INC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * BRENT
IF Corporation, enter Registered Agent First %rre
3. Last Name* WASHBURN
It Corporation, enter Fbgistered Agent Last %ne
3b. Title WASHBURN BUILDING CONTRACTORS, INC
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-748-9208
Telephone No.*
6. Permittee Mailing Street Address
Address* 233 Charlotte Rd
Address Line 2
City
State / Rovince / F;bgion
Rutherfordton
NC
Fbstal / Zip Code
Country
28115
USA
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
233 Charlotte Rd
Address Line 2
City
State / Frovince / Region
Rutherfordton
NC
Fbstal / Zip Code
Country
28115
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Project Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site BRENT
Contact - First
Name *
2. Primary Site WASHBURN
Contact - Last
Name*
3. Title PRESIDENT
4. Site Contact E- [e-mail]
mail Address*
5. Site Contact 828-748-9203
Telephone No.*
6. Organization
ODOM ENGINEERING, PLLC
Name
7. Site Contact
Street Address
Mailing Address*
233 Charlotte Rd
Address Line 2
city
Rutherfordton
Pbstal / Zip Code
28139
8. Consultant Name (Optional)
First and Last nave
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Province / Region
North Carolina
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 07/30/2020
Approved *
2. E&SC Plan Project RUTHE-2021-002
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Asheville (ARO)
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
Hunter's Glen SEC APPROVAL WASHBURN
Approval letter or
496.43KB
BUILDERS BS WOT.pdf
Grading Permit
Mast be RDFforrrat
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)
Frovide 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
WASHBURN BUILDING CONTRACTORS NOI
Form
493.11 KB
SIGNED.pdf
Mast be FDFfon-rat
This is an Express
r No
Review Project*
r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) 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 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 * Brent Washburn
Title PRESIDENT
Organization Legally Plesponsible Entity
WASHBURN BUILDING CONTRACTORS, INC
Date * 08/14/2020

F. Tracking and COC Info
NOI Tracking No. 29926
NC Reference No.
NCG01-2020-3564
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203564
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3564
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. NCC203564-2020
Invoice Due Date 9/16/2020
Initial Fee $ 100.00
Invoice Status OPEN