NCC212777_NOI Application_20210528

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/4/2021 10:51:04 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 5/6/2021 4:12:21 PM (Review- Construction NOI 52059)
• The task was assigned to Garcia, Lauren V by round robin distribution 5/4/2021 10:52 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 6, 2021 5:00 PM
5/4/2021 10:52 AM
Submit by Selkane, Aziza 5/28/2021 10:10:36 AM (Payment Verification for NCC212777)
* Richard Bowen
• Selkane, Aziza assigned the task to Selkane, Aziza 5/28/2021 10:09 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 17, 2021 5:00 PM
5/6/2021 4:12 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
F No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Fishers Ridge Lots 1 - 51
1 b. Specific Lot
This field rray be used to list specifc lot nunbers.
Numbers

1 c. Parcel ID List all RNIs associated w ith this project.
Number(s) (PIN) 069500-83-9050
069500-93-1110
069500-93-2379
069500-93-3475
069500-93-4475
069500-93-5494
069500-93-7414
069500-93-8454
160500-03-0404
160500-03-1424
160500-03-2424
160500-03-3424
160500-03-4424
160500-03-5424
160500-03-6423
160500-03-7432
160500-03-9417
160500-03-9626
160500-03-6781
160500-03-5760
160500-03-4770
160500-03-3781
160500-03-2791
160500-03-2701
160500-03-0644
160500-03-0754
160500-03-0864
160500-03-1952
160500-03-2973
160500-03-3981
160500-03-4991
160500-03-6807
160500-03-7817
160500-03-9918
160500-04-7137
160500-04-5285
160500-04-4188
160500-04-4108
160500-04-3398
160500-04-1065
160500-04-1297
160500-04-0295
069500-94-9189
069500-94-8181
069500-93-8926
069500-93-7881
069500-93-7647
069500-93-4740
069500-93-4838
069500-94-3094
069500-94-4192
069500-94-6034
2. County* Johnston
3. Highway or Street 26 Rio Grande Lane
Address * Street narre only is acceptable if no address nun ber assigned yet
4. City or Township* Pleasant Grove

5. State * NC
6. Zip Code* 27592
7. Latitude* Enter the latitude in decimal degrees
35.5438
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-78.6679
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*
05/10/2021
Estimated Construction Project Start Rate
10. Date to End *
05/10/2023
Estimated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
29.40
disturbed*
(including off -site borrow and waste areas)
13. Total site area 58.64
(acres) *
14. Post- 8.80
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-JOHNS-2021-Fishers Ridge Lots 1 - 51
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 Black Creek
Wate rbody* %rre of waterbody into which stormwater runoff will discharge
15b. Waterbody 27-45-(2)
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. ^
Fbrnittee 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 * KB Home Raleigh -Durham, Inc.
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 * Richard
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Bowen
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Director, Land Development
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-427-3775
Telephone No.*
6. Permittee Mailing Street Address
Address* 4506 S Miami Blvd
Address Line 2
Suite 100
City
Durham
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
27703-8000
V Yes
Street Address
4506 S Miami Blvd
Address Line 2
Suite 100
city
Durham
Fbstal / Zip Code
27703-8000
State / Ffovince / Fbgion
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
Richard
Contact - First
Name *
2. Primary Site
Bowen
Contact - Last
Name *
3. Title
Director, Land Development
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-427-3775
Telephone No.
6. Organization
KB Home Raleigh -Durham, Inc.
Name
7. Site Contact
Street Address
Mailing Address*
4601 South Miami Boulevard
Address Line 2
Suite 100
city
Durham
Fbstal / Zip Code
27703
8. Consultant Name
(Optional)
Fleet Temple
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-894-7765
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
919-427-3775
Default is legally responsible person telephone
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 04/09/2021
Approved *
2. E&SC Plan Project JC#20-014-P
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston County
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 20-014 Fisher's Ridge Subdivision Lots 1-51 ESC
Approval letter or 591.63KB
Appr 4.09.21.pdf
Grading Permit
Mast be FL7Ffon-rat
6. Site Location Map Wst be RDFforrret (lint 201VB)
vici n ity. pdf 9.37KB
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 NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 80.37KB
SWSIGNED.pdf
Mast be RDFfon-rat
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* Richard T. Bowen
Title Director, Land Development
Organization Legally Pesponsible Entity
KB Home Raleigh -Durham, Inc.
Date * 05/04/2021

F. Tracking and COC Info
NOI Tracking No. 52059
NC Reference No.
NCG01-2021-2777
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC212777
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2777
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. NCC212777-2021
Invoice Due Date 6/5/2021
Initial Fee $ 100.00
Invoice Status OPEN