NCC216381_NOI Application_20211203

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/12/2021 8:43:59 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 11/12/2021 12:16:14 PM (Review - Construction NOI 73045)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 11/12/2021 8:44 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 16, 2021 5:00
PM 11/12/2021 8:44 AM
Submit by Evans, Shaundra M 12/3/2021 10:59:28 AM (Payment Verification for NCC216381)
F Lenin J Petewrs
• Evans, Shaundra M assigned the task to Evans, Shaundra M 12/3/2021 10:58 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: December 24, 2021 5:00
PM 11/12/2021 12:16 PM

NORTH CAROLINA
Rrf Omrlm&tral Qualrly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting No
an NOI that was Yes
rejected before?
la. Project Name* Multi -Tenant Bldg on D Street
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
3A
1 c. Parcel ID
List all PINs associated with this project.
Number(s) (PIN)
1406011
2. County*
Wilkes
3. Highway or Street 1013
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* North Wilkesboro
5. State* NC
6. Zip Code* 28659
7. Latitude* Enter the latitude in decimal degrees
36.1594
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
-81.1513
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*
11/15/2021
Estimated Construction Project Start Date
10. Date to End*
03/07/2022
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be
1.41
disturbed *
(including off -site borrow and waste areas)

13. Total site area 1.52
(acres)*
14. Post -construction 1.09
impervious area (Estimated)
(acres) *
Project Tracking ID NCC-WILKE-2021-Multi-Tenant Bldg on D Street
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 Reddies River
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody Index 12-40-(10)
No. * NC Waterbody Index Number
Stormwater No
discharges will flow Yes
to additional waters*
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Permittee Information - Legally Responsible 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
1. Permittee* Legally Responsible Entity
Peters Development, LLC
If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC
SPCA Financial Responsibility/Ownership (FRO) Form.
2. First Name* Lenin J.
If Corporation, enter Registered Agent First Name
3. Last Name* Peters
If Corporation, enter Registered Agent Last Name
3b. Title CEO
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-252-2207
Telephone No.*
6. Permittee Mailing Street Address
Address* 645 N. Main Street
Address Line 2
City State / Province / Region
High Point NC
Postal / Zip Code Country
27262 United States
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address *
645 N. Main Street
Address Line 2
City
State / Province / Region
High Point
NC
Postal / Zip Code
Country
27262
United States
8. Type of
Ownership is only individual if an individual
is named in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Project Site Contact Information
.................................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Robert
Contact - First
Name*
2. Primary Site Melvin
Contact - Last Name*
3. Title Commercial Construction Manager
4. Site Contact E-mail [e-mail]
Address*
5. Site Contact
Telephone No.*
6. Organization Name
7. Site Contact
Mailing Address*
704-252-2207
Street Address
645 North Main Street
Address Line 2
City
High Point
Postal / Zip Code
27262
8. Consultant Name (optional)
W. Jesse Hanlin, PE
First and Last name
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 336-838-2500
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-mail
12. Billing Telephone (For Annual Fee correspondence)
704-252-2207
Default is legally responsible person telephone
State / Province / Region
NC
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC Plan 10/19/2021
Approved *
2. E&SC Plan Project WILKE-2022-003
Number/ID* Assigned by agency or local program
3. E&SC Plan State DEQ Office
Approved by* Local Program
4. State DEQ Office* Winston-Salem (WSRO)
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
LoA WILKE-2022-003_20211019.pdf
199.26KB
Approval letter or
Must be PDF format
Grading Permit
6. Signed FRO
Financial Responsibility/Ownership Form
Signed NCDEQ FRO.pdf
270.38KB
Must be PDF format
7. Site Location Map
Must be PDF format (limit 20 MB)
BRE-20014 Bethany Medical Center, Sheet C-1
833.36KB
Revised 10-18-2021.pdf
Please do not upload entire set of E&SC plans.
8. Notes (Optional)
Provide any additional information that might help the reviewer better understand how uploaded documents
support the application. Include additional waterbodies if necessary.
9. NOI Certification
SIGNED NOI Peters
Form
384.53KB
Development _20211105_122706.pdf
Must be PDF format
This is an Express • No
Review Project* Yes

E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false 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 Article; or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* 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.
* 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.
* I will abide by all conditions of the NCG010000 General Permit and the approved
Erosion and Sediment Control Plan.
* 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:* The Legally Responsible Person named on this Notice of Intent
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* Lenin J. Peters
Title CEO
Organization Legally Responsible Entity
Peters Development, LLC
Date * 11 /12/2021

F. Tracking and COC Info
NOI Tracking No. 73045
NC Reference No.
NCG01-2021-6381
Uses'count_numb& variable (incremented by SP)
Certificate of
NCC216381
Coverage (COC) No.*
Uses'count_number' variable (incremented by SP)
Count Number
6381
Sequential number for submittal that is incremented by Stored Procedure
COC Year
2021
Year of date reviewed (used to assign YY digits after "NCC" in COC no.)
Initial Invoice No. NCC216381-2021
Invoice Due Date 12/12/2021
Initial Fee $ 100.00
Invoice Status OPEN