NCC215169_NOI Application_20211005

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/13/2021 2:58:33 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 9/14/2021 6:35:08 AM (Review- Construction NOI 64710)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 9/13/2021 2:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 15, 2021 5:00
PM 9/13/2021 2:59 PM
Submit by Evans, Shaundra M 10/5/2021 7:58:53 AM (Payment Verification for NCC215169)
* Don Peeler Realty Inc
• Evans, Shaundra M assigned the task to Evans, Shaundra M 10/5/2021 7:57 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 26, 2021 5:00 PM
9/14/2021 6:36 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting
f• No
an NOI that was
r Yes
rejected before?
1a. Project Name *
Pinnacle Estates
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 22555472005, 2555376200, 2555376222, 2555370246
2. County* Cleveland
3. Highway or Street Joe's Lake Road
Address* Street name only is acceptable if no address number assigned yet
4.CityorTownship* Shelby
5. State * NC
6. Zip Code* 28152
7. Latitude* Enter the latitude in decimal degrees
35.2554
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-81.5006
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*
10/11/2021
Estirrated Construction Project Start Rate
10. Date to End*
10/11/2022
Estinated Construction Project End Cate
11. SIC (Primary)*
Residential, Single Family Houses (SFE) (1521)
Standard Industrial aassification for Development
12. Acres to be
24.00
disturbed*
(including off -site borrow and waste areas)

13. Total site area 25.34
(acres) *
14. Post- 8.14
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-CLEVE-2021-Pinnacle Estates
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 Roberts Branch
Waterbody* Narreof waterbody into which stormwater runoff will discharge
15b. Waterbody 9-53-7-(1)
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.
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 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
LGI Homes - NC, LLC
It pernittee is an individual, enter first and last narre in this field. Ctherwise, 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 * Jeff
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Webb
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Authorized Officer
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-297-0693
Telephone No.*
6. Permittee Mailing Street Address
Address* 6500 Creedmoor Road
Address Line 2
Suite 212
City State / Ffovince / Fbgion
Raleigh NC
Fbstal / Zip Code Country
27613-3698 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 6500 Creedmoor Road
Address Line 2
Suite 212
City
State / Ftovince / Faegion
Raleigh
NC
Fbstal / Zip Code
Country
27613-3698
us
8. Type of ONnership 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
Kenny
Contact - First
Name *
2. Primary Site
Gray
Contact - Last
Name *
3. Title
Land Development Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7047180907
Telephone No.
6. Organization
LGI Homes
Name
7. Site Contact
Street Address
Mailing Address*
6500 Creedmoor Road
Address Line 2
city
Raleigh
Fbstal / Zip Code
27613-3698
8. Consultant Name
(Optional)
Caleb Peeler
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
7046924212
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
704-297-0693
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 08/26/2021
Approved *
2. E&SC Plan Project CLEVE-2022-003
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 * Mooresville (MRO)
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 ESC Approval - Pin nacle_20210825.pdf 1.57MB
Approval letter or Mast beRDFforml
Grading Permit
6. Signed FRO Financial Pesponsibility/Ojvnership Form
FRO Form - Notarized.pdf 570.76KB
Mist be RDFfornat
7. Site Location Map Mast be RDFforrrat (lirrit 20IVB)
USGS Aerial Location Map.pdf 3.15MB
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 NOI Certification Form_Signed.pdf 356.27KB
Form Mast be FDFforrrat
This is an Express F 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:* r The Legally Responsible Person named on this Notice of Intent
r 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 * Jeff Webb
Title Authorized Officer
Organization Legally Responsible Entity
LGI Homes - NC, LLC
Date * 09/13/2021

F. Tracking and COC Info
NOI Tracking No. 64710
NC Reference No.
NCG01-2021-5169
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC215169
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5169
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. NCC215169-2021
Invoice Due Date 10/14/2021
Initial Fee $ 100.00
Invoice Status OPEN