NCC205814_NOI Application_20201230

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/14/2020 2:38:13 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 12/15/2020 4:21:05 PM (Review- Construction NOI 39062)
• The task was assigned to Garcia, Lauren V by round robin distribution 12/14/2020 2:38 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 16, 2020 5:00
PM 12/14/2020 2:38 PM
Submit by McCoy, Suzanne 12/30/2020 2:29:59 PM (Payment Verification for NCC205814)
* SECU cashiers check
• McCoy, Suzanne assigned the task to McCoy, Suzanne 12/30/2020 2:29 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 26, 2021 5:00 PM
12/15/2020 4:21 PM

.• SThF� ';
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 39045
NOI No.
Prior Reviewer Michael Meloy
Name
1a. Project Name * Guiford Preparatory Academy
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 126504
2. County* Guilford
3. Highway or Street 2240 E. Cone Blvd.
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Greensboro
5. State * NC
6. Zip Code* 27405
7. Latitude* Enter the latitude in decimal degrees
36.1110
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.7410
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* 12/17/2020
Estimated Construction Project Start Date
10. Date to End* 08/01/2021
Estimated Construction Project End Date

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 7.30
disturbed* (including off -site borrow and waste areas)
13. Total site area 25.03
(acres) *
14. Post- 4.39
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-GUILF-2020-Guiford Preparatory Academy
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 North Buffalo Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 16-11-14-1
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 * Impact Builders, Inc.
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 * Christopher
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Bordeaux
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Vice -President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-876-7495
Telephone No.*
6. Permittee Mailing Street Address
Address* 1207 Front Street, Ste. 200
Address Line 2
City
Raleigh
Fbstal / Zip Code
27609
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
us
7. Permittee Street
Street Address
Address*
1207 Front Street, Ste. 200
Address Line 2
city
State / Frovince / Faegion
Raleigh
NC
Fbstal / Zip Code
Country
27609
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
Rick
Contact - First
Name *
2. Primary Site
Williamson
Contact - Last
Name *
3. Title
Senior Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
850-544-8119
Telephone No.*
6. Organization
LAI Construction Management
Name
7. Site Contact
Street Address
Mailing Address*
9911 Corkscrew Rd. Ste 202
Address Line 2
City
State / Rovince / Region
Estero
Florida
Fbstal / Zip Code
Country
33928
us
8. Consultant Name
(Optional)
Richard Lossee
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
239-405-6890
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NOts may not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NOIs rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 12/10/2020
Approved *
2. E&SC Plan Project 3015
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Greensboro
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 Approval Letter [2020-1381] [EC3015].pdf 378.29KB
Approval letter or Mast beRDFforml
Grading Permit
6. Site Location Map Wst be RDFfornat (lint 20 NB)
2020-11-20 Guilford Prep Academy SitePlan.pdf 1.16MB
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 if necessary.
8. NOI Certification Guilford Prep_NOI_12.14.2020.pdf 645.01KB
Form Wst be RDFfornat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle 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 If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 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* Christopher Bordeaux
Title Vice -President
Organization Legally Ibsponsible Entity
Impact Builders Inc
Date * 12/14/2020

F. Tracking and COC Info
NOI Tracking No. 39062
NC Reference No.
NCG01-2020-5814
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205814
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5814
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. NCC205814-2020
Invoice Due Date 1/14/2021
Initial Fee $ 100.00
Invoice Status OPEN