NCC204841_NOI Application_20201215

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/23/2020 9:46:24 AM (NCG01 NOI Submission)
Approve by Morman, Alaina 10/26/2020 4:48:44 PM (Review- Construction NOI 33893)
• Morman, Alaina reassigned the task to Morman, Alaina 10/23/2020 9:59 AM
• The task was assigned to Meloy, Michael by round robin distribution 10/23/2020 9:46 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 27, 2020 5:00
PM 10/23/2020 9:46 AM
Submit by Selkane, Aziza 12/15/2020 11:53:20 AM (Payment Verification for NCC204841)
* Stephen A Rosenburgh
• Selkane, Aziza assigned the task to Selkane, Aziza 12/15/2020 11:52 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 7, 2020 5:00
PM 10/26/2020 4:49 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 33590
NOI No.
Prior Reviewer Alaina Morman
Name
1a. Project Name * Providence Commons
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all PIS associated w ith this project.
Number(s) (PIN)
2. County* Union
3. Highway or Street 3701 Providence Road South
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Waxhaw
5. State * NC
6. Zip Code* 28173
7. Latitude* Enter the latitude in decimal degrees
34.9428
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.7514
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* 10/26/2020
Estimated Construction Project Start Date
10. Date to End * 10/06/2021
Estimated Construction Project End Date

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 17.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 27.50
(acres) *
14. Post- 0.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-UNION-2020-Providence Commons
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 Blythe Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 11-138-2-6
Index No. * NCWaterbody Index Nurrber
Stormwater V 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 * 3701 S. Providence Properties, LLC
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 * Stephen
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Rosenburgh
It Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7045760022
Telephone No.*
6. Permittee Mailing Street Address
Address* 5925 Carnegie Boulevard
Address Line 2
Suite 200
Cty
Charlotte
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
28209-4655
F Yes
Street Address
5925 Carnegie Boulevard
Address Line 2
Suite 200
city
Charlotte
Fbstal / Zip Code
28209-4655
State / Ffovince / Pegion
NC
Country
us
State / Ftovince / Region
NC
Country
us
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Stephen
Contact - First
Name *
2. Primary Site
Rosenburgh
Contact - Last
Name *
3. Title
President
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7045760022
Telephone No.
6. Organization
3701 S. Providence Properties, LLC
Name
7. Site Contact
Street Address
Mailing Address*
5925 Carnegie Boulevard
Address Line 2
Suite 200
city
Charlotte
Postal / Zip Code
28209-4655
8. Consultant Name
(Optional)
Robb KLAUK
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7043330325
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 05/09/2019
Approved *
2. E&SC Plan Project UNION-2019-054
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 * Mooresville (MRO)
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 NCDEQ EC Approval 2019-05-13.pdf 185.99KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mast be RDFfornat (lint 20 NB)
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Provide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies for linear projects if necessary.
This erosion control permit is only for Clearing & grubbing and
mass grading of the site. There is no impervious area at this time.
We will be submitting under separate projects the development of
the parcel and will request additional NOI with the individual
projects.
8. NOI Certification NCG01 Form 10.21.20.pdf 1.35MB
Form Mast be RDFformat
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 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 Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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 * Stephen Rosenburgh
Title President
Organization Legally Plesponsible Entity
3701 S. Providence Properties, LLC
Date * 10/23/2020

F. Tracking and COC Info
NOI Tracking No. 33893
NC Reference No. NCG01-2020-4841
Uses 'count_nunber' variable (increrrented by SP)
Certificate of NCC204841
Coverage (COC) Uses 'count nurrber' variable (increrrented by SP)
No.*
Count Number 4841
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. NCC204841-2020
Invoice Due Date 11/25/2020
Initial Fee $ 100.00
Invoice Status OPEN