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HomeMy WebLinkAboutNCC211388_NOI Application_20210309Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 3/5/2021 4:42:21 PM (NCG01 NOI Submission) Approve by Garcia, Lauren V 3/8/2021 1:17:26 PM (Review- Construction NOI 47347) • The task was assigned to Garcia, Lauren V by round robin distribution 3/5/2021 4:43 PM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 9, 2021 5:00 PM 3/5/2021 4:43 PM Submit by Selkane, Aziza 3/9/2021 11:34:06 AM (Payment Verification for NCC211388) * Sarah Maness • Selkane, Aziza assigned the task to Selkane, Aziza 3/9/2021 11:33 AM The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 19, 2021 5:00 PM 3/8/2021 1:17 PM .• SThF� '; 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 * City of Winston-Salem - Fire Station 3 1 b. Specific Lot This field may be used to list specifc lot numbers. Numbers 013 and 019 1 c. Parcel ID List all Rios associated w ith this project. Number(s) (PIN) 6836-67-0527; 6836-57-9643 2. County* Forsyth 3. Highway or Street 2995 N. Liberty Street Address* Street name only is acceptable if no address number assigned yet 4. Cityor Township* Winston-Salem 5. State * NC 6. Zip Code* 27105 7. Latitude* Enter the latitude in decimal degrees 36.1280 8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative) -80.2326 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* 05/01/2021 Estimated Construction Project Start Rate 10. Date to End* 05/01/2022 Estinated Construction Project End Date 11. SIC (Primary)* Commercial (1542) Standard Industrial aassification for Development 12. Acres to be 1.70 disturbed* (including off -site borrow and waste areas) 13. Total site area 1.92 (acres) * 14. Post- 0.70 construction (Estirreted) impervious area (acres) * NCC Project NCC-FORSY-2021-City of Winston-Salem - Fire Station 3 Tracking ID 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 Brushy Fork Waterbody* Narreof waterbody into which storrrwater runoff will discharge 15b. Waterbody 12-94-12-6 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. ^ Fternittee 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 * City of Winston-Salem 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 * Lee If Corporation, enter Faegistered Agent First %rre 3. Last Name* Garrity It Corporation, enter Pbegistered Agent Last %rre 3b. Title City Manager 4. Permitee E-mail leeg@cityofws.org Address* 5. Permittee (336) 747-7380 Telephone No.* 6. Permittee Mailing Street Address Address* P.O. Box2511 Address Line 2 City Winston-Salem Fbstal / Zip Code 27102 Check box if the street address the same as mailing address 7. Permittee Street Address* F Yes Street Address 100 East 1 st Street Address Line 2 city Winston-Salem Fbstal / Zip Code 27101 State / Ffovince / Fbgion North Carolina Country United States State / Frovince / Region NC Country US 8. Type of Ownership is only individual if an individual is naned in B. 1. above. Ownership* Government- Municipal C. Site Contact Information Part C. Roject Site Contact Inforrration .................................................................................................................................................................................................... 1. Primary Site Robert Contact - First Name * 2. Primary Site Prestwood Contact - Last Name * 3. Title City Engineer 4. Site Contact E- robertp@cityofws.org mail Address* 5. Site Contact (336) 747-6985 Telephone No. 6. Organization City of Winston-Salem Name 7. Site Contact Street Address Mailing Address* P.O. Box2511 Address Line 2 city Winston-Salem Fbstal / Zip Code 27102 8. Consultant Name (Optional) Kevin Davie First and Last narre 9. Consultant E-mail kevin@allied-engsurv.com This person will be copied on all correspondence. 10. Consultant (336) 397-1217 Telephone No. 11. Billing E-mail (For Annual Fee correspondence) leeg@cityofws.org Default is legally responsible person e-rrail 12. Billing (For Annual Fee correspondence) Telephone (336) 747-7380 Default is legally responsible person telephone State / Rovince / Region NC Country USA D. E&SC Plan Part D. ^ Erosion & Sediment Control (E&SC) Ran Approval Information ...................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 02/25/2021 Approved * 2. E&SC Plan Project FORSY-2021-028 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 * Winston-Salem (WSRO) Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can include the beginning point and end point coordinates in the "Notes" box below). 5. E&SC Plan APPROVED - NCDEQ Erosion Control 2-25-21.PDF 49.68KB Approval letter or Mast beRDFformat Grading Permit 6. Site Location Map Mist be RDFformat (lint 20 W) C7-FINAL GRADING.pdf 890.3KB Rease do not upload entire set of E&SC plans. 7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support the application. Include additional waterbodies if necessary. 8. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR- Form 74.41 KB SW.CWSFireStation3.signed.pdf Mast be R7Fformat 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* Lee Garrity Title City Manager Organization Legally Plesponsible Entity City of Winston-Salem Date * 03/05/2021 F. Tracking and COC Info NOI Tracking No. 47347 NC Reference No. NCG01-2021-1388 Uses 'count_nurrber' variable (increrrented by SP) Certificate of NCC211388 Coverage (COC) Uses 'count_nurrber' variable (increrrented by SP) No.* Count Number 1388 Sequential nurrber for subrrittal that is incremented by Stored Frocedure COC Year 2021 Year of date reviewed (used to assign YY digits after "NOC' in COCno.) Initial Invoice No. NCC211388-2021 Invoice Due Date 4/7/2021 Initial Fee $ 100.00 Invoice Status OPEN