NCC215568_NOI Application_20211007

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/5/2021 2:32:24 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 10/6/2021 8:06:49 AM (Review- Construction NOI 67960)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 10/5/2021 2:33 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 7, 2021 5:00
PM. The priority is: High 10/5/2021 2:33 PM
Submit by Evans, Shaundra M 10/7/2021 8:25:05 AM (Payment Verification for NCC215568)
* Daniel Shelton
• Evans, Shaundra M assigned the task to Evans, Shaundra M 10/7/2021 8:24 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 17, 2021 5:00
PM. The priority is: High 10/6/2021 8:07 AM

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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 66771
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name * Sentara Albemarle Medical Center - Phase 1 Medical Office Building
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 8903 48172
2. County* Pasquotank
3. Highway or Street 905 Thunder Road
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Elizabeth City
5. State * NC
6. Zip Code* 27909
7. Latitude* Enter the latitude in decinal degrees
36.3000
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-76.2680
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* 09/30/2021
Estirrated Construction Project Start Date
10. Date to End* 08/31/2024
Estinated Construction Project End Date

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 21.59
disturbed* (including off -site borrow and waste areas)
13. Total site area 34.51
(acres) *
14. Post- 13.02
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-PASQU-2021-Sentara Albemarle Medical Center - Phase 1
Medical Office Building
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 Pasquotank River
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 30-3-(7)
Index No. * NCWaterbody Index Nurrber
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
MPB, Inc. d/b/a MPB, Inc. Carolina
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 * Aubrey
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Layne
It Corporation, enter F;bgistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 757-594-1011
Telephone No.*
6. Permittee Mailing Street Address
Address* 160 Mine Lake Ct.
Address Line 2
Suite 200
Cty
Raleigh
Fbstal / Zip Code
27615
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
160 Mine Lake Ct.
Address Line 2
Suite 200
city
Raleigh
Fbstal / Zip Code
27615
State / Ffovince / Fbgion
NC
Country
us
State / Frovince / Region
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
Patrick
Contact - First
Name *
2. Primary Site
O'Bryan
Contact - Last
Name *
3. Title
Superintendent
4. Site Contact E-
patrick.o'[e-mail]
mail Address*
5. Site Contact
757-592-5484
Telephone No.*
6. Organization
The Whiting -Turner Contracting Company
Name
7. Site Contact
Street Address
Mailing Address*
1317 Executive Boulevard
Address Line 2
Suite 120
City
State / Rovince / Region
Chesapeake
VA
Postal / Zip Code
Country
23320
us
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant 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
757-652-1709
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/28/2021
Approved *
2. E&SC Plan Project Pasqu-2022-004
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 * Washington (WaRO)
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 Pasqu-2022-004 Sentara Albemarle Medical Center
Approval letter or - Phase 1 Medical Office Building - 09282021 1.09MB
Grading Permit
(EXP).pdf
Mast be REF format
6. Signed FRO Financial Responsibility/Ownership Form
Financial Responsibility -Ownership Form —REV
171.34KB
LOD.pdf
Mast be RDFfornat
7. Site Location Map Mast be RDFfornat (linit 20IVB)
Site Layout Plan.pdf 715.85KB
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 eNOI-Certification-Form-SAMC Phase 1.pdf 814.73KB
Form Mast be RDFfornat
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:* 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
L
Type Name* Aubrey Layne
Title President
Organization Legally Plesponsible Entity
MPB, Inc. d/b/a. MPB, Inc. Carolina
Date * 10/05/2021

F. Tracking and COC Info
NOI Tracking No. 67960
NC Reference No.
NCG01-2021-5568
Uses 'count_nunber' variable (increrrented by SP)
Certificate of
NCC215568
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5568
Sequential nunber for subnittal 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. NCC215568-2021
Invoice Due Date 11/5/2021
Initial Fee $ 100.00
Invoice Status OPEN