NCC213686_NOI Application_20210623

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/17/2021 12:30:26 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 6/18/2021 7:29:54 AM (Review- Construction NOI 56716)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 6/17/2021 12:31 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 21, 2021 5:00 PM
6/17/2021 12:31 PM
Submit by McCoy, Suzanne 6/23/2021 12:39:16 PM (Payment Verification for NCC213686)
* Northlake Developers LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 6/23/2021 12:38 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 30, 2021 5:00 PM
6/18/2021 7:30 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 56544
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Fox Hills IREDE-2021-084
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) 4649387122.000, 4649482102.000, 4649475851.000
2. County* Iredell
3. Highway or Street Carlyle Road
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Troutman
5. State * NC
6. Zip Code* 28166
7. Latitude* Enter the latitude in decinal degrees
35.6539
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.8724
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* 06/16/2021
Estinated Construction Project Start Date
10. Date to End * 06/15/2022
Estirrated Construction Project End Late

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 8.18
disturbed* (including off -site borrow and waste areas)
13. Total site area 28.00
(acres) *
14. Post- 6.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-IREDE-2021-Fox Hills IREDE-2021-084
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 Hobbs Creek
Waterbody* %rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-87-(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. ^
Fl rnittee 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 * Northlake Deveopers 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 * Bruce
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Kososki
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Managing Partner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 980 829 4090
Telephone No.*
6. Permittee Mailing Street Address
Address* 110 Nautical Point Court
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
110 Nautical Point Court
Address Line 2
city
Mooresville
Fbstal / Zip Code
28117
State / Frovince / Fbgion
NC
Country
us
State / Frovince / Faegion
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
Bruce
Contact - First
Name *
2. Primary Site
Kososki
Contact - Last
Name *
3. Title
Managing Partner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
980 829 4090
Telephone No.
6. Organization
Northlake Developers LLc
Name
7. Site Contact
Street Address
Mailing Address*
110 Nautical Point Court
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
980 829 4090
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 06/09/2021
Approved *
2. E&SC Plan Project IREDE-2021-084
Number/ID * Assigned by agency or local program
3. E&SC Plan
Approved by*
4. Local Program*
f State DEQ Office
r Local Program
Iredell 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 Fox Hills Erosion Control Permit.pdf 1.87MB
Approval letter or Mist beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrrat (lint 201VB)
Location Map Carlyle Rd project.pdf 146.12KB
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 documents support
the application. Include additional waterbodies if necessary.
Location of the project site drains downhill to Hobbs Creek, to the
south east of the project site.
8. NOI Certification Fox Hills NCGO1 NOI Certification form signed.pdf 838.49KB
Form Mist be RDFformat
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* Bruce Kososki
Title Managing Partner
Organization Legally Ibsponsible Entity
Northlake Developers LLC
Date * 06/17/2021

F. Tracking and COC Info
NOI Tracking No. 56716
NC Reference No.
NCG01-2021-3686
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC213686
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3686
Sequential nunber for subnittal 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. NCC213686-2021
Invoice Due Date 7/18/2021
Initial Fee $ 100.00
Invoice Status OPEN