NCC214287_NOI Application_20210728

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/23/2021 3:04:02 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 7/26/2021 7:54:07 AM (Review- Construction NOI 59815)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 7/23/2021 3:04 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 27, 2021 5:00 PM
7/23/2021 3:04 PM
Submit by Selkane, Aziza 7/28/2021 6:29:30 AM (Payment Verification for NCC214287)
* Jarvis Kennedy Custom Homes, LLC
• Selkane, Aziza assigned the task to Selkane, Aziza 7/28/2021 6:28 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 6, 2021 5:00
PM 7/26/2021 7:54 AM

.• SThF� ';
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 59725
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Jarvis - Kennedy Custom Homes, LLC
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
NA
1 c. Parcel ID
List all RW associated w ith this project.
Number(s) (PIN)
5807612017, 580719611297
2. County*
Yadkin
3. Highway or Street w. Lee Avenue
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Yadkinville
5. State * NC
6. Zip Code* 27055
7. Latitude* Enter the latitude in decimal degrees
36.1318
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.6734
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* 08/02/2021
Estimated Construction Project Start Date
10. Date to End * 07/29/2022
Estimated Construction Project End Date

11. SIC (Primary)* Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be 2.52
disturbed* (including off -site borrow and waste areas)
13. Total site area 6.90
(acres) *
14. Post- 1.07
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-YADKI-2021-Jarvis - Kennedy Custom Homes, LLC
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 Haw Branch
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 12-84-1-3
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. ^
Fbrnittee 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 * Mark A Jarvis
IF 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 * Mark
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Jarvis
IF Corporation, enter F;bgistered Agent Last %rre
3b. Title Owner
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-399-2559
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box515
Address Line 2
City
Lewisville
Fbstal / Zip Code
27023
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Pegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
837 Newington Dr
Address Line 2
city
State / Frovince / Faegion
Clemmons
NC
Fbstal / Zip Code
Country
27012-8839
US
8. Type of
Ownership is only individual if an individual
is naned in B.1. above.
Ownership*
Individual

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Mark
Contact - First
Name *
2. Primary Site
Jarvis
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-399-2559
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
837 Newington Dr
Address Line 2
city
Clemmons
Fbstal / Zip Code
27012-8839
8. Consultant Name
(Optional)
Paul Fidishun
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-765-1923
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
336-399-2559
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 07/16/2021
Approved *
2. E&SC Plan Project YADKI-2022-001
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r 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 Jarvis - Kennedy Custom Homes LLC NCDEQ Letter
Approval letter or 72.3KB
of Approval.pdf
Grading Permit
Mist be FDFforrrat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Vicinity Map.pdf 21.71 KB
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 NCG01 - Jarvis Kennedy.pdf 1.12MB
Form Mist 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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; 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 Artcle 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 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:* IT The Legally Responsible Person named on this Notice of Intent
f 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 * Mark Jarvis
Title Owner
Organization Legally Responsible Entity
Owner
Date * 07/23/2021

F. Tracking and COC Info
NOI Tracking No. 59815
NC Reference No.
NCG01-2021-4287
Uses 'count_nurber' variable (increrrented by SP)
Certificate of
NCC214287
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4287
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. NCC214287-2021
Invoice Due Date 8/25/2021
Initial Fee $ 100.00
Invoice Status OPEN