NCC190869_NOI Application_20190708

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/8/2019 3:25:22 PM(NCG01 NOI Submission)
Approve by Clark, Paul 7/8/2019 4:10:07 PM(Review-Construction NOI 13162)
In For the record, the signature on E-Certification is difficult to read.
• The task was assigned to Clark, Paul by round robin distribution 7/8/2019 3:25 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 10,2019 5:00 PM
7/8/2019 3:25 PM
Submit by Clark, Paul 7/8/2019 4:12:03 PM(Payment Verification-NCG01-2019-0869)
• The task was assigned to Clark, Paul.The due date is:July 9,2019 5:00 PM 7/8/2019 4:10 PM

1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Ernvlronmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* NGIC Parking Lot
2. County* Forsyth
3. Highway or Street Hanes Mill Road
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Winston-Salem
5. State* NC
6.Zip Code* 27105
7. Latitude* Enter the latitude in decirral degrees
36.1788
8. Longitude* Enter the longitude in decirral degrees(MJSTbe negative)
-80.2819
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* 07/11/2019
Estimated Construction Project Start Date
10. Date to End* 09/30/2019
Estimated Construction Project End Date
11. SIC(Primary)* Commercial(1542)
Standard Industrial gassification for Developrrant
12.Acres to be 2.20
disturbed* (including off-site borrow and waste areas)
13.Total site area 15.47
(acres)*
14. Post- 1.55
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-FORSY-2019-NGIC Parking Lot
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. You may
enter up to 3 waterbodies.
15a. Receiving Mill Creek
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b.Waterbody 12-94-7
Index No.* NCWaterbody Index Nunber
Stormwater rJ 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.
Perrrittee 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 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 National General Insurance Company
Name*
2. First Name* David
ff Corporation,enter Registered Agent First l\brre
3. Last Name* Wolf
ff Corporation,enter Registered Agent Last Barre
3b.Title Vice President Real Estate
4. Permitee E-mail [e-mail]
Address*
5. Permittee 212-430-0011
Telephone No.*
6. Permittee Mailing Street Address
Address* 59 Maiden Lane
Address Line 2
City State/Province/Region
New York W
Postal/Zip Code Country
10038 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 59 Maiden Lane
Address Line 2
City State/Province/Region
New York W
Pastal/Zip Code Country
10038 US

C. Site Contact Information
Part C.
Project Site Contact Information
....................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Gerard
Contact-First
Name*
3.Primary Site Perreault
Contact-Last
Name*
4.Title Project Manager
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 336-331-9407
Telephone No.*
7.Organization Magnolia Construction LLC
Name
8.Site Contact Street Address
Mailing Address* 514 South Stratford Road
Address Line 2
City State/Province/Fegion
Winston-Salem NC
Fbstal/Zip Code Country
27103 us

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 07/01/2019
Approved*
2. E&SC Plan Project EN1900055
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Winston-Salem/Forsyth County
Documentation of E&SC Plan approval and the signed Notice of Intent(NOI)Certification Form is required for a
complete application.
5. E&SC Plan Review Completed-NGIC Parking Lot.pdf 213.88KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NOI form NGIC.pdf 60.06KB
Form Mist be RJFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B(1)provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled or required to be maintained under this Article or a rule implementing this Article;or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars($10,000).
Under penalty of law, I certify that:
rJ 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.
* I7 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.
* I7 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 Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important:The person who signs this Certification above and signs the NOI Certification Form should be the same
person(or authorized responsible person within the same organization)as listed in Section B(Permittee Information)
of this form. *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* David Wolf
Title Vice President Real Estate
Organization National General Insurance Company
Date* 07/08/2019

F. Tracking and COC Info
NOI Tracking No. 13162
NC Reference No. NCG01-2019-0869
Uses'count number variable(incremented by SP)
Certificate of NCC190869
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 869
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NGC'in OOCno.)