NCC215183_NOI Application_20210915

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/14/2021 9:58:21 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 9/14/2021 10:03:24 AM (Review- Construction NOI 64768)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 9/14/2021 9:59 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 16, 2021 5:00
PM 9/14/2021 9:59 AM
Submit by Miller, Ariyelle L 9/15/2021 10:47:29 AM (Payment Verification for NCC215183)
* AndrewDreyfuss
• Miller, Ariyelle L assigned the task to Miller, Ariyelle L 9/15/2021 10:39 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 26, 2021 5:00 PM
9/14/2021 10:03 AM

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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 *
Villas at Jefferson Ridge
1 b. Specific Lot
This field rray be used to list speck lot numbers.
Numbers
1 c. Parcel ID List all RED associated w ith this project.
Number(s) (PIN) 6806742647000, 6806752166000, 6806742847000, 6806742973000,
6806742998000,6806752094000,6806753171000,6806745917000,
6806744856000,6806744752000
2. County* Forsyth
3. Highway or Street Albemarle Court
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Winston-Salem
5. State * NC
6. Zip Code * 27106
7. Latitude * Enter the latitude in decimal degrees
36.1186
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.3294
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*
10/01/2021
Estimated Construction Project Start Date
10. Date to End*
10/01/2022
Estimated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial C]assification for Development
12. Acres to be
4.33
disturbed*
(including off -site borrow and waste areas)

13. Total site area 7.02
(acres) *
14. Post- 1.46
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-FORSY-2021-Villas at Jefferson Ridge
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 Muddy Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-94-(0.5)
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.
Fl rnittee 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 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Permittee * Legally Pesponsible Entity
Nova Jefferson, LLC
It pernittee is an individual, enter first and last narre in this field. otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Andrew
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Dreyfuss
It Corporation, enter Pegistered Agent Last %rre
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 206b N Spruce St
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27101
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
206b N Spruce St
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27101
State / Frovince / Pegion
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
Andrew
Contact - First
Name *
2. Primary Site
Dreyfuss
Contact - Last
Name *
3. Title
Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
[phone]
Telephone No.
6. Organization
Nova Jefferson, LLC
Name
7. Site Contact
Street Address
Mailing Address*
206 North Spruce Street
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27101-2747
8. Consultant Name
(Optional)
Aden Stoltzfus
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
[phone]
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
[phone]
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 09/13/2021
Approved *
2. E&SC Plan Project EN1800062
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. 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
2021-09-13 Villas at Jefferson Ridge Erosion
Approval letter or
213.5KB
Permit.pdf
Grading Permit
Mast be RDFforrrat
6. Signed FRO
Financial Pesponsibility/Ojvnership Form
Villas at Jefferson Ridge FRO-Signed.pdf 97.69KB
Mast be RDFfornat
7. Site Location Map
Mast be R7Ffon-rat (lirrit 20 NB)
Villas at Jefferson Ridge Site Map-1.pdf 336.86KB
Rease do not upload entire set of E&SC plans.
8. Notes (Optional)
Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies if necessary.
9. NOI Certification J Ridge NG01.pdf 398.62KB
Form Mast be RDFforrrat
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 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* Andrew Dreyfuss
Title Manager
Organization Legally Ibsponsible Entity
Nova Jefferson, LLC
Date * 09/14/2021

F. Tracking and COC Info
NOI Tracking No. 64768
NC Reference No.
NCG01-2021-5183
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC215183
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5183
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. NCC215183-2021
Invoice Due Date 10/14/2021
Initial Fee $ 100.00
Invoice Status OPEN