NCC204085_NOI Application_20200923

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/14/2020 4:27:38 PM (NCG01 NOI Submission)
Approve by Gwinn, Matt 9/17/2020 2:40:29 PM (Review- Construction NOI 31422)
• The task was assigned to Gwinn, Matt by round robin distribution 9/14/2020 4:28 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 16, 2020 5:00
PM 9/14/2020 4:28 PM
Submit by Selkane, Aziza 9/23/2020 8:08:12 AM (Payment Verification for NCC204085)
* Thomas J Ellis
• Selkane, Aziza assigned the task to Selkane, Aziza 9/23/2020 8:07 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 29, 2020 5:00 PM
9/17/2020 2:40 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 * ST1240 - FY18 Sidewalks Ederlee Drive & Tryon Road Penny
Road
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers
2. County* Wake
3. Highway or Street Ederlee Drive, Tyron Road, Penny Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Cary
5. State * NC
6. Zip Code* 27513
7. Latitude* Enter the latitude in decimal degrees
35.7150
8. Longitude * Enter the longitude in decimal degrees (K JST be negative)
-78.7980
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*
10/05/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2021
Estinated Construction Project End Cate
11. SIC (Primary) *
Highway (1611)
Standard Industrial C]assification for Development
12. Acres to be
1.84
disturbed*
(including off -site borrow and waste areas)
13. Total site area 2.42
(acres) *

14. Post- 2.42
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-WAKE-2020-ST1240 - FY18 Sidewalks Ederlee Drive & Tryon
Tracking ID Road Penny Road
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, Regency Park Lake,
Waterbody*
Swift Creek
%rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody
27-43-4.5, 27-43-2.5,
Index No.*
27-43-(1)
NC Waterbody Index Number
Stormwater
rJ 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. ^
Fbrnittee 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 * Town of Cary
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Tom
If Corporation, enter Registered Agent First Wre
3. Last Name* Ellis
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Senior Project Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-469-4333
Telephone No.*
6. Permittee Mailing Street Address
Address* 316 North Academy Street
Address Line 2
PO Box 8005
City
Cary
Fbstal / Zip Code
27512
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 316 North Academy Street
Address Line 2
State / Frovince / i egion
NC
Country
us
city State / Frovince / Region
Cary NC
Fbstal / Zip Code Country
27513-4538 us
8. Type of Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Tom
Contact - First
Name *
2. Primary Site
Ellis
Contact - Last
Name *
3. Title
Senior Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-469-4333
Telephone No.
6. Organization
Town of Cary
Name
7. Site Contact
Street Address
Mailing Address*
316 North Academy Street
Address Line 2
PO Box 8005
Oty
Cary
Fbstal / Zip Code
27512
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 09/03/2020
Approved *
2. E&SC Plan Project WAKE-2020-006
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 * Raleigh (RRO)
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 WAKE-2020-006_20200903_LOA.pdf 375.14KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Mast be FCFfornat. 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 NC G01 eNO1 Certification Form Completed.pdf 686.11 KB
Form Mist be RDFfornat
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 11:3" UAA
Type Name * Tom Ellis
Title Senior Project Manager
Organization Legally Responsible Entity
Town of Cary
Date * 09/14/2020

F. Tracking and COC Info
NOI Tracking No. 31422
NC Reference No.
NCG01-2020-4085
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC204085
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4085
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. NCC204085-2020
Invoice Due Date 10/17/2020
Initial Fee $ 100.00
Invoice Status OPEN