NCC240078_NOI Signed Certification_20240116

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68(i), 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. . . 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(check all boxes to indicate your agreement):
lEj 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.
• If the approved Erosion and Sediment Control Plan 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.
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.
Project Name(must match Ala):'i IS b ,J �k L7�Apj a.fI y „-a®` '-vo s'
Specific Lot Numbers(must match Alb): I Ol43 mcb f -y tAf rS
Permittee (must match 81): ere,livo H Vc)
Legally Responsible Person (must match 82& 83): Torn VA))c)-I z 2 e+4 H-
Title of Legally Responsible Person (must match 83b): G'€i>E'rI) V r y
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: J©(p �j / ^Q )
- � IMP)
.gnature of Legally Responsible Person or Authorized Individual Date
* IMP RTANT NOTE: This form must be signed by a responsible corporate officer that 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 8,
Item(6)of the NCG010000 permit.

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A. y, �
1. Project Name� J� /� )/I V 04k,.J3J )Z C L 1a 7`'
`-C) '--
2. Location of land-disturbing activity: County 0 to l City or Township) L)f 1--) )i
1.2 / 35,0397 8- Zt�37
Hi hway/S eet Latitude(decimal degrees) LOngitUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: 7/ 1 i- /DC J, 3
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Tedd
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed $ /CO.(( The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? YesYeskl Enclosed k No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
V Name1OM a `/C hI E-mail Address I y�M )e CG'�T) 11�r �S C15-1
Phone: Office# 7(,Z E9 fo O 1 ) Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
> ? e00 )a
Name Phone: Office# Mobile#
I acfricCURA-� -- -
Current Mailing Address Current Street Address
City State Zip City State Zip
3 10 Deed Book No. Page No.1 Provide a copy of the most current deed

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
eY Hz &) 1-I0 _s r-)-7r1-)-7C7br1 ti9-ocrc '' s . con
Company Name E-mail Address
e20, 0 .D i ��-
Current Mailing Address Current Street Address
1--ha a se e-C 3094 L,„
City State /� Zip City State Zip
Phone: Office#-201efq� O9) Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Torn Vat 1;c_hk6 S r €r 20
Type or .rint name Title or Authority
Alva-
40 a
S`•nature
I, 1 --C\I ` 7-J-t-, , a Notary Public of the County of lCi.4JfS
or
State of epl: k-Csxetl f +ea, hereby certify that 17 ) Vo ) -)- k'' appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of JaflvOifl , 20 at-
, c71/4N SM/ry N
S N°TARS 5, i1a�.
My commission expires
EXR 05/01/2026
Ot�

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No, Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No _ _ Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

...
I
` STATF."
gad � ' o
rF�• y /� ,T
ROY COOPER ,
Governor r 4 ELIZABETH S.BISER ��`, �. a��
Secretary :i?uAM
WILLIAM E.TOBY VINSON,JR NORTH CAROLINA
Interim Director Environmental Quality
January 3, 2024
LETTER OF APPROVAL WITH MODIFICATIONS
Brown Haven Homes LLC
ATTN:Mr.John Allen
102 Town Square
Blairsville, GA 28906
RE: Project Name:JOSEPH&GAYLE INTAG CLAY-2024-002
Acres Approved: 0.5
Project ID: CLAY-2024-002
County: Clay
City: Hayesville
Address: McGlamery Farms Dr.
River Basin: Hiwassee
Stream Classification: Downing Creek, Hiwassee River- Class C&WS-IV
Submitted By:W. Gary Kendall
Date Received by LQS: December 14,2023
Plan Type: Residential
Dear Mr.Allen,
This office has reviewed the subject erosion and sedimentation control plan. We find
the plan to be acceptable with modifications and hereby issue this letter of Approval with
Modifications.The Modifications Required for Approval are listed on the attached page.This
plan approval shall expire three (3) years following the date of approval, if no land-
disturbing activity has been undertaken,as is required by Title 15A NCAC 4B.0129.
As of April 1, 2019, all new construction activities are required to complete and submit an
electronic Notice of Intent(eNOI) form requesting a Certificate of Coverage (COC) under the
NCG010000 Construction General Permit. After the form is reviewed and found to be
complete,you will receive a link with payment instructions for the $100 annual permit fee.
After the fee is processed,you will receive the COC via email. As the Financially Responsible
Party shown on the FRO form submitted for this project,you MUST obtain the COC prior to
commencement of any land disturbing activity. The eNOI form may be accessed at
li g(.gov/NCG01. Please direct questions about the eNOI form to the Stormwater Program
staff in the Raleigh central office. If the owner/operator of this project changes in the future,
the new responsible party must obtain a new COC.
N DE
) North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
` Asheville Regional Office 12090 U.S.Highway 70 I Swannanoa.North Carolina 28778
°^" V "...,,°.." 828.296.4500

Letter of Approval with Modifications
Brown Haven Homes LLC
ATTN: Mr.John Allen
January 3,2024
Page 2 of 3
Title 15A NCAC 4B.0118(a)and the NCG01 permit require that the following documentation
be kept on file at the job site:
I. The approved E&SC plan as well as any approved deviation.
2. The NCG01 permit and the COC,once it is received.
3. Records of inspections made during the previous 12 months.
Also, this letter gives the notice required by G.S. 113A-61.1(a) of our right of periodic
inspection to ensure compliance with the approved plan.
North Carolina's Sedimentation Pollution Control Act is performance-oriented, requiring
protection of existing natural resources and adjoining properties. If, following the
commencement of this project, it is determined that the erosion and sedimentation control
plan is inadequate to meet the requirements of the Sedimentation Pollution Control Act of
1973 (North Carolina General Statute 113A-51 through 66),this office may require revisions
to the plan and implementation of the revisions to ensure compliance with the Act.
Acceptance and approval of this plan is conditioned upon your compliance with Federal and
State water quality laws, regulations,and rules. In addition, local city or county ordinances
or rules may also apply to this land-disturbing activity. This approval does not supersede
any other permit or approval.
Please note that this approval is based in part on the accuracy of the information provided
in the Financial Responsibility Form, which you provided. You are requested to file an
amended form if there is any change in the information included on the form. In addition,it
would be helpful if you notify this office of the proposed starting date for this project.
Your cooperation is appreciated.
Sincerely, / I n
9J
Fred Walker, PE
Engineer III
Land Quality Section
Enclosures: Certificate of Approval
NPDES NCG01 Fact Sheet
ec: Savannah Leduc-NCDEQ-LQS ([e-mail])
Anthony Stillwell- Clay County ([e-mail])
Tracy Smith ([e-mail])
cc: Regional Office file

Letter of Approval with Modifications
Brown Haven Homes LLC
ATTN: Mr.John Allen
January 3, 2024
Page 3 of 3
MODIFICATIONS REQUIRED FOR APPROVAL
Project Name: JOSEPH&GAYLE INTAG CLAY-2024-002
Project ID: CLAY-2024-002
County: Clay
1. Provide an original notarized Financial Responsibility/Ownership form with Part B.1
completed to match information provided on the N.C. Secretary of State corporation
search webpage. Complete Part B.2.a with information provided on the NCSOS
corporation search webpage,the address should be revised in Part B.2.a to Blairsville,
Georgia.