NCC215599_NOI Application_20211011

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/7/2021 7:57:06 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 10/7/2021 8:06:53 AM (Review- Construction NOI 68123)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 10/7/2021 7:57 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 11, 2021 5:00
PM 10/7/2021 7:57 AM
Submit by Evans, Shaundra M 10/11/2021 9:21:17 AM (Payment Verification for NCC215599)
* Jon Grabowski
• Evans, Shaundra M assigned the task to Evans, Shaundra M 10/11/2021 9:20 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 18, 2021 5:00
PM 10/7/2021 8:07 AM

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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 *
SURREY WOODS
1 b. Specific Lot
This field any be used to list specifc lot numbers.
Numbers
1 - 28
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 03517439
03517444
03517438
2. County* Mecklenburg
3. Highway or Street 155 Baucom Street
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Charlotte
5. State * NC
6. Zip Code * 28216
7. Latitude * Enter the latitude in decimal degrees
35.3050
8. Longitude * Enter the longitude in decimal degrees (M-STbe negative)
-80.9300
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*
10/18/2021
Estirrated Construction Project Start Date
10. Date to End *
10/18/2022
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial C]assification for Development
12. Acres to be
8.10
disturbed*
(including off -site borrow and waste areas)

13. Total site area 9.37
(acres) *
14. Post- 3.43
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-MECKL-2021-SURREY WOODS
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 Gum Branch
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 11-120-5
Index No. * NCWaterbody Index Number
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 must 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. Permittee * Legally Pesponsible Entity
Cedar Trail CLT, LLC
It pernittee is an individual, enter first and last narre in this field. Otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Jon
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Grabowski
It Corporation, enter Pegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 313-600-7248
Telephone No.*
6. Permittee Mailing Street Address
Address* 2208 Retana Drive
Address Line 2
City
Charlotte
Fbstal / Zip Code
28270
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
2208 Retana Drive
Address Line 2
City
Charlotte
Fbstal / Zip Code
28270
State / Frovince / Pegion
NC
Country
Mecklenburg
State / Frovince / Faegion
NC
Country
Mecklenburg
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
Eddie
Contact - First
Name *
2. Primary Site
Massey
Contact - Last
Name *
3. Title
General Contractor
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7042015935
Telephone No.
6. Organization
Banks Massey Grading Co.lnc.
Name
7. Site Contact
Street Address
Mailing Address*
5402
Address Line 2
Rocky River Rd.
city
Oakboro
Fbstal / Zip Code
28129
8. Consultant Name
(Optional)
First and Last narre
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
313-600-7248
Default is legally responsible person telephone
State / Rovince / Region
North Carolina
Country
USA

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/01/2021
Approved *
2. E&SC Plan Project LDGP-2021-00233
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Charlotte
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 SURREY WOODS LETTER OF APPROVAL.pdf 1.73MB
Approval letter or Mast beRDFforml
Grading Permit
6. Signed FRO Financial Pesponsibility/Ojvnership Form
SURREY WOODS RESPONSIBLE.pdf 1.9MB
Mist be RDFfornat
7. Site Location Map Mist be RDFforrrat (lirrit 20 NB)
SURREY WOODS SITE MAP.pdf 1.71 MB
Rease do not upload entire set of E&SC plans.
8. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies if necessary.
9. NOI Certification SURREY WOODS NOI CERTIFICATION FORM. pdf 1.39MB
Form Mast be RDFfon-rat
This is an Express F 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
Type Name* Jon Grabowski
Title Manager
Organization Legally Ibsponsible Entity
Cedar Trail CLT. LLC
Date * 10/07/2021

F. Tracking and COC Info
NOI Tracking No. 68123
NC Reference No.
NCG01-2021-5599
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC215599
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5599
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. NCC215599-2021
Invoice Due Date 11/6/2021
Initial Fee $ 100.00
Invoice Status OPEN