NCC205821_NOI Application_20201217

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/16/2020 9:50:46 AM (NCG01 NOI Submission)
Approve by Meloy, Michael 12/16/2020 10:46:53 AM (Review- Construction NOI 39258)
• The task was assigned to Meloy, Michael by round robin distribution 12/16/2020 9:51 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 18, 2020 5:00
PM 12/16/2020 9:51 AM
Submit by Selkane, Aziza 12/17/2020 8:14:50 AM (Payment Verification for NCC205821)
* Lorraine Rivera
• Selkane, Aziza assigned the task to Selkane, Aziza 12/17/2020 8:14 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 27, 2021 5:00 PM
12/16/2020 10:47 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 39205
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Kathryns Retreat - Individual lots 37-47, 49-56, 66-9, 71-73. 85-88
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers Individual lots 37-47, 49-56, 66-9, 71-73. 85
88
1 c. Parcel ID List all RIB associated w ith this project.
Number(s) (PIN) 040674152101000 21
2. County* Harnett
3. Highway or Street South Wilma
Address* Street name only is acceptable if no address number assigned yet
4. Cityor Township* Angier
5. State * NC
6. Zip Code * 27501
7. Latitude* Enter the latitude in decimal degrees
35.4981
8. Longitude * Enter the longitude in decimal degrees (M-ISTbe negative)
-78.7309
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* 03/24/2020
Estimated Construction Project Start Date
10. Date to End* 06/13/2021
Estimated Construction Project End Date

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 4.80
disturbed* (including off -site borrow and waste areas)
13. Total site area 4.80
(acres) *
14. Post- 4.80
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-HARNE-2020-Kathryns Retreat - Individual lots 37-47, 49-56,
Tracking ID 66-9, 71-73. 85-88
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 Black River
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 18-68-12-1a
Index No. * NCWaterbody Index Number
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 Fa sponsible 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 * Capitol City Homes
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 * Jason
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Morrow
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Managing Partner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9198720048
Telephone No.*
6. Permittee Mailing Street Address
Address* 5711 Six Forks Road
Address Line 2
5711 Six Forks Rd, Suite 200, Raleigh,
NC 27609
City
State / Ffovince / Pegion
Raleigh
NC
Fbstal / Zip Code
Country
27609-3888
us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 5711 Six Forks Road
Address Line 2
5711 Six Forks Rd, Suite 200, Raleigh,
NC 27609
City
State / Ftovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27609-3888
us
8. Type of ONnership 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
Kevin
Contact - First
Name *
2. Primary Site
Cheek
Contact - Last
Name *
3. Title
Area Project Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9194140360
Telephone No.*
6. Organization
Capitol City Homes
Name
7. Site Contact
Street Address
Mailing Address*
5711 Six Forks Rd,
Address Line 2
Suite 200
City
State / Rovince / Region
Raleigh
NC
Fbstal / Zip Code
Country
27609
United States
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-rail (older NOts may not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NOls ray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/24/2020
Approved *
2. E&SC Plan Project HARNE-2020-103
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 * Fayetteville (FRO)
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 Letter & Certificate DEQ NCGOI LR Lots 37-47, 49,
Approval letter or 178.05KB
56, 66-69, 71-73, 85-88.pdf
Grading Permit
Mist be FCFfon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Site Location Map.pdf 339.74KB
Rease do not upload entire set of E&SC plans.
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 NCG01 - NOI.pdf 37.6KB
Form Mist be RDFforrret
This is an Express r 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:* IT 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 * Jason Morrow
Title Managing Partner
Organization Legally Responsible Entity
Capitol City Homes, LLC
Date * 12/16/2020

F. Tracking and COC Info
NOI Tracking No. 39258
NC Reference No. NCG01-2020-5821
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of NCC205821
Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5821
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. NCC205821-2020
Invoice Due Date 1/15/2021
Initial Fee $ 100.00
Invoice Status OPEN