NCC214325_NOI Application_20210728

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/27/2021 10:29:36 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 7/27/2021 10:42:27 AM (Review- Construction NOI 60001)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 7/27/2021 10:30 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 29, 2021 5:00 PM
7/27/2021 10:30 AM
Submit by Selkane, Aziza 7/28/2021 7:32:07 AM (Payment Verification for NCC214325)
* Agnieszka Nau
• Selkane, Aziza assigned the task to Selkane, Aziza 7/28/2021 7:31 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 7, 2021 5:00
PM 7/27/2021 10:43 AM

.• SThF� ';
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* Lakestone Subdivision Lots: 1,2,4-7,9,10,16,19,21,25-29,31,37,44,50-53
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers 1,2,4-7,9,10,16,19,21,25-29,31,37,44,50-53
1 c. Parcel ID
List all Rios associated w ith this project.
Number(s) (PIN)
1850282002
1850282076
1850283094
1850284092
1850286001
1850287029
1850284253
1850285237
1850380653
1850382873
1850284432
1850287538
1850287692
1850288648
1850288774
1850289844
1850286884
1850282559
1850188205
1850281524
1850282332
1850281274
1850281108
1850280131
2. County*
Wake
3. Highway or Street Wait Ave & Stone Park
Address* Street narre only is acceptable if no address number assigned yet
4. CityorTownship* Wake Forest
5. State * NC

6. Zip Code * 27587
7. Latitude* Enter the latitude in decimal degrees
35.9699
8. Longitude * Enter the longitude in decimal degrees (MJST be negative)
-78.4839
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 Rate
10. Date to End *
07/01 /2022
Estimated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
9.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 24.00
(acres) *
14. Post- 3.00
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-WAKE-2021-Lakestone Subdivision Lots: 1,2,4-
7,9,10,16,19,21,25-29,31,37,44,50-53
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 Smith Creek (Wake Forest Reservoir)
Waterbody * N Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 27-23-(1.5)
Index No.* NCWaterbody Index Number
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Smith Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 27-23-(2)
Index No. NCWaterbody Index Number
15e. Additional Waterbody nacre
Receiving
Waterbody

15f. Waterbody
Index No.
NC Waterbody Index Mbrrber
16a. Is this project
subject to the NC
Sediment Pollution
Control Act?*
r Yes
r No, not subject to NC SPCA

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 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 * Baker Residential LLC
It 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 * Jeffrey
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Havener
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Director of Land Development
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-694-7602
Telephone No.*
6. Permittee Mailing Street Address
Address* 7001 Weston Parkway
Address Line 2
Suite 150
City
Cary
Fbstal / Zip Code
27513
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
7001 Weston Parkway
Address Line 2
Suite 150
City
Cary
Fbstal / Zip Code
27513
State / Ffovince / i egion
NC
Country
us
State / Frovince / Faegion
NC
Country
us
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
Jeffrey
Contact - First
Name *
2. Primary Site
Havener
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-694-7602
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
7001 Weston Parkway
Address Line 2
Suite 150
city
Cary
Fbstal / Zip Code
27513
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
[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
919-694-7602
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 07/20/2021
Approved *
2. E&SC Plan Project 2021-00001785
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Town of Wake Forest
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
Approval Letter Lakestone Lots - Baker Residential
Approval letter or
98.5KB
ESC LoA.pdf
Grading Permit
Mist be FDFfon-rat
6. Site Location Map
Mist be RDFforrrat (lint 20 NB)
C2 - LAKESTONE - DISTURBED AREA PLAN.pdf 2.43MB
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-eNO1-Certification- Form. pdf 1.79MB
Form
Mist be RDF format
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 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
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* Jeffrey Havener
Title Director of Land Development
Organization Legally Ibsponsible Entity
Baker Residential
Date * 07/27/2021

F. Tracking and COC Info
NOI Tracking No. 60001
NC Reference No.
NCG01-2021-4325
Uses 'count_nurber' variable (increrrented by SP)
Certificate of
NCC214325
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4325
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. NCC214325-2021
Invoice Due Date 8/26/2021
Initial Fee $ 100.00
Invoice Status OPEN