NCC213883_NOI Application_20210701

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/29/2021 1:32:30 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 6/30/2021 8:40:01 AM (Review- Construction NOI 57478)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 6/29/2021 1:33 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 1, 2021 5:00 PM
6/29/2021 1:33 PM
Submit by Selkane, Aziza 7/1/2021 12:15:28 PM (Payment Verification for NCC213883)
* Widan E Dickinson
• Selkane, Aziza assigned the task to Selkane, Aziza 7/1/2021 12:13 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 11, 2021 5:00 PM
6/30/2021 8:40 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 57458
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Larkin/ Fox Den Phase 4
1 b. Specific Lot
This field any be used to list specifc lot numbers.
Numbers
22,24,25,26,27,34,53,89
1 c. Parcel ID
List all RW associated w ith this project.
Number(s) (PIN)
4743609044.000
4742791928.000
4743701087.000
4743700135.000
4743701124.000
4743704407.000
4743702804.000
4743701732.000
2. County*
Iredell
3. Highway or Street 186 Wedge View Way
Address* Street name only is acceptable if no address number assigned yet
4.CityorTownship* Statesville
5. State * NC
6. Zip Code* 28677
7. Latitude* Enter the latitude in decimal degrees
35.7431
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.8648
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*
06/30/2021
Estinated Construction Project Start Date
10. Date to End*
11/30/2021
Estirrated Construction Project End Date
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Leveloprrent
12. Acres to be
9.08
disturbed*
(including off -site borrow and waste areas)
13. Total site area 9.08
(acres) *
14. Post- 0.50
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-IREDE-2021-Larkin/ Fox Den Phase 4
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 Third Creek (Third Creek WS No. 37)
Waterbody* %rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-108-20-4
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. ^
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 * West Homes of NC, LLC
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 * Earl
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Dickinson
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 8042918481
Telephone No.*
6. Permittee Mailing Street Address
Address* 1207 Roseneath Rd
Address Line 2
City
Richmond
Fbstal / Zip Code
23226
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
1207 Roseneath Rd
Address Line 2
City
Richmond
Fbstal / Zip Code
23226
State / Frovince / Pegion
VA
Country
USA
State / Frovince / Faegion
VA
Country
USA
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
Mitch
Contact - First
Name *
2. Primary Site
Kamphuis
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9194412545
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
116 Wedge View Way
Address Line 2
city
Statesville
Fbstal / Zip Code
28677
8. Consultant Name
(Optional)
First and Last nave
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
8042918481
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 09/19/2019
Approved *
2. E&SC Plan Project STVLE-2020-018
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 Den Lots West Homes LOA (002).pdf 57.19KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrrat (lint 20 NB)
Fox Den —Recorded Plats —Phase IV Maps.pdf 6.78MB
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.
8. NOI Certification NOI.pdf 438.51KB
Form Wst be RDFforrrat
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* Earl Dickinson
Title Manager
Organization Legally Ibsponsible Entity
West Homes of NC, LLC
Date * 06/29/2021

F. Tracking and COC Info
NOI Tracking No. 57478
NC Reference No.
NCG01-2021-3883
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC213883
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3883
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. NCC213883-2021
Invoice Due Date 7/30/2021
Initial Fee $ 100.00
Invoice Status OPEN