NCC204304_NOI Application_20200929

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/25/2020 4:47:04 PM (NCG01 NOI Submission)
Approve by Clark, Paul 9/28/2020 2:46:46 PM (Review- Construction NOI 32066)
• Garcia, Lauren V reassigned the task to Clark, Paul 9/28/2020 9:22 AM
• The task was assigned to Garcia, Lauren V by round robin distribution 9/25/2020 4:47 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 29, 2020 5:00
PM. The priority is: High 9/25/2020 4:47 PM
Submit by Selkane, Aziza 9/29/2020 10:24:14 AM (Payment Verification for NCC204304)
* Vincent O. Burgess IV
• Selkane, Aziza assigned the task to Selkane, Aziza 9/29/2020 10:20 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 9, 2020 5:00 PM.
The priority is: High 9/28/2020 2:47 PM

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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 31984
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Burgess Corporation
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
2. County* New Hanover
3. Highway or Street 3700 US HWY 421 N
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Wilmington
5. State * NC
6. Zip Code * 28401
7. Latitude * Enter the latitude in decimal degrees
34.2950
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-77.9710
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* 09/23/2020
Estimated Construction Project Start Date
10. Date to End* 09/01/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Developrrent

12. Acres to be 6.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 8.40
(acres) *
14. Post- 8.40
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-NEW I-1-2020-Burgess Corporation
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 Northeast Cape Fear River
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 18-74-(52.5)
Index No.* NCWaterbody 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. ^
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 * Burgess Corporation
It 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 * Vincent
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Burgess
It Corporation, enter Pbegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-990-2484
Telephone No.*
6. Permittee Mailing Street Address
Address* 1551 Point Harbor Road
Address Line 2
City
Wilmington
Fbstal / Zip Code
28401-2576
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 1551 Point Harbor Road
Address Line 2
State / Frovince / Pegion
NC
Country
us
city
State / Frovince / Region
Wilmington
NC
Fbstal / Zip Code
Country
28401-2576
us
8. Type of Individual
Ownership *

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Scott
Contact - First
Name *
2. Primary Site
Ross
Contact - Last
Name *
3. Title
Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-540-9847
Telephone No.
6. Organization
Burgess Corporation
Name
7. Site Contact
Street Address
Mailing Address*
1551 Point Harbor Road
Address Line 2
city
Wilmington
Fbstal / Zip Code
28401
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
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 04/12/2020
Approved *
2. E&SC Plan Project LNDP 19-00206
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 * Wilmington (WiRO)
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
NCG101 Notice of Intent.pdf 8.66MB
Approval letter or
Mast beRDFformat
Grading Permit
6. Site Location Map
Helpful for linear project review
(Optional)
Erosion & Sediment Control Plan (Drawings).pdf 4.76MB
Mast be RDF format. 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
705.12KB
SW.pdf
Mast be RDFfon-rat
This is an Express
r No
Review Project*
F 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 * Vincent Burgess
Title President
Organization Legally Plesponsible Entity
Burgess Corporation
Date * 09/25/2020

F. Tracking and COC Info
NOI Tracking No. 32066
NC Reference No.
NCG01-2020-4304
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC204304
Coverage (COC)
Uses 'count nurrber' variable (increrrented by SP)
No.*
Count Number 4304
Sequential nunber for subnittal 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. NCC204304-2020
Invoice Due Date 10/28/2020
Initial Fee $ 100.00
Invoice Status OPEN