NCC214484_NOI Application_20210809

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/5/2021 1:30:41 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/6/2021 7:21:28 AM (Review- Construction NOI 61435)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/5/2021 1:31 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 9, 2021 5:00
PM 8/5/2021 1:31 PM
Submit by McCoy, Suzanne 8/9/2021 1:11:25 PM (Payment Verification for NCC214484)
* Hilltop Free Will Baptist Church
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/9/2021 1:10 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 17, 2021 5:00
PM 8/6/2021 7:22 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 59990
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Hilltop Baptist Church- Classroom Expansion
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
n/a
1 c. Parcel ID
List all RW associated w ith this project.
Number(s) (PIN)
0688-23-5515, 0688-13-9036, 0688-13-8207, 0688-23-9573, 0688-13-9546,
0688-23-0732,0688-33-0428
2. County*
Wake
3. Highway or Street 10212 Fayetteville Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Fuquay-Varina
5. State * NC
6. Zip Code * 27526
7. Latitude* Enter the latitude in decimal degrees
35.6278
8. Longitude * Enter the longitude in decimal degrees (M-ISTbe negative)
-78.7214
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* 08/09/2021
Estimated Construction Project Start Date
10. Date to End* 08/01/2022
Estimated Construction Project End Cate

11. SIC (Primary)* Other (9999)
Standard Industrial aasslfication for Development
12. Acres to be 13.00
disturbed* (including off -site borrow and waste areas)
13. Total site area 26.83
(acres) *
14. Post- 2.05
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-WAKE-2021-Hilltop Baptist Church- Classroom Expansion
Assigned automatically (not used)
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 UT to Neuse River via Middle Creek
Waterbody* %rreof waterbody into which stormwater runoff will discharge
15b. Waterbody 27-43-15-(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. ^
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 * Hilltop Free Will Baptist Church of Fuquay-Varina
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 * Jeff
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Jones
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Pastor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-422-6126
Telephone No.*
6. Permittee Mailing Street Address
Address* 10212 Fayetteville Road
Address Line 2
City
State / Frovince / Region
Fuquay-Varina
NC
Fbstal / Zip Code
Country
27526-8503
us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
10212 Fayetteville Road
Address Line 2
City
State / Frovince / Faegion
Fuquay-Varina
NC
Postal / Zip Code
Country
27526-8503
us
8. Type of
ONnership 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
Jason
Contact - First
Name *
2. Primary Site
Pleasants
Contact - Last
Name *
3. Title
Vice President, Executive Supervisor
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-422-7401
Telephone No.
6. Organization
Kenneth West, Inc
Name
7. Site Contact
Street Address
Mailing Address*
800 Bricksteel Lane
Address Line 2
city
Garner
Fbstal / Zip Code
27529
8. Consultant Name
(Optional)
Kristi Anspach
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-883-8211
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
919-422-6126
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 11/23/2020
Approved *
2. E&SC Plan Project EC-2020-24
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Fuquay-Varina
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 HilltopBaptistClassroom_EC Approval_11.23.20.pdf 100.07KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Vicinity Map.pdf 2.01 MB
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 Doc - Aug 5 2021 - 1-28 PM.pdf 625.81 KB
Form Wst be RDFforrret
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
IT 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
.Iy01 7111r
Type Name* Jeffrey B Jones
Title Pastor & President
Organization Legally Ibsponsible Entity
Hilltop Free Will Baptist Church of Fuquay-Varina
Date * 08/05/2021

F. Tracking and COC Info
NOI Tracking No. 61435
NC Reference No.
NCG01-2021-4484
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC214484
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4484
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. NCC214484-2021
Invoice Due Date 9/5/2021
Initial Fee $ 100.00
Invoice Status OPEN