SWA000199_Application Form_20230418

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
SW Program(s): ❑ Coastal SA-HQW ❑ Coastal SA-ORW ❑ Coastal FW-ORW ❑ Coastal Other
❑ Non -coastal HQW ❑ Non -coastal ORW ❑ Urbanizing Areas ❑ USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions
A. ELIGIBILITY FOR FAST -TRACK PERMITTING
To be considered for a Fast Track ATC Permit, all of the items below must be checked. If any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project) will meet all applicable
requirements of 15A NCAC 02H .1000 - .1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® I understand that at project completion, an application with the as -built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as -built stormwater plans to confirm
compliance with the MDC. Approval of the as -built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name: Arbor Domus Treehouse Development
2. Previous Project Name (if applicable): n/a
3. Location of Project (street address): Clarks Creek Road
City:Foscoe Community County:Watauga Zip:28604
4. Directions to project (from nearest major intersection):
From the intersection of NC Hwy 105 and Clarks Creek Road travel north 0.9 miles on Clarks Creek Road;
the subject property will be on the left must past Ridge Haven Parkway
5. Latitude:360 10' 14.06" N Longitude:-81 ° 46' 6.00" W of the main entrance to the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit -- provide previous permit number: SWA
Stormwater Fast Track ATC Application Form Page 1 of 10 Feb. 10. 2018

By choosing this option, you are also requesting that DEQ rescind the previous Fast Track A TC Permit
upon issuance of the new Fast Track A TC Permit.
Stormwater Fast Track ATC Application Form Page 2 of 10 Feb. 10,2018

❑ Major Modification, replacing an existing stormwater permit — provide existing permit number: SW
Status of construction? ❑ Not Started ❑ Partially Completed ❑ Completed
Major modifications must be submitted by the original permittee and are allowed only if the SW permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track ATC Permit.
❑ Transfer of existing Fast Track ATC Permit — provide existing ATC permit number: SWA
Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ❑ Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ® Non -Coastal HQW
Is any portion of the project within 575 feet
of SA-ORW waters? ❑ Yes ❑ No ❑ Non -Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal — Other
3. Other Permits (as applicable; write "NA" for those permit types that are not applicable):
Project Name
Permit/Appl
Issue Date
Other Information
No.
CAMA Major
n/a
NA
Erosion &
Arbor Domus Treehouse
20220013
2-6-23
Disturbed Area 2.11
Sedimentation Control
acre
Develo ment
NPDES Industrial
n/a
NA
Stormwater
404/401 Permit
n/a
Proposed Impacts
If/ac
4. Local jurisdiction for building permits: Watauga County
Point of Contact:Chris Grub Phone #: (828 ) 265-8043
D. CONTACT INFORMATION
1. Applicant/Financially Responsible Party (may be an Organization):Treehouse Luxe, LLC
Signing Official Name & Title:Paul Niemyski, Managing Member
Street Address:6902 Lakeshore Drive
City:Dallas
Mailing Address (if different):
City:_
Phone:
Email:
State:TX Zip:75214
State:
Fax: ( )
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered Agent:Capitol Corporate Services Inc.
Mailing Address:176 Mine Lake CT Suite 100
City -.Raleigh State: NC Zip:27615
Phone: [phone] Fax: ( )
Email: regagent(a-),capitolservices.com
Stormwater Fast Track ATC Application Form Page 3 of 10 Feb. 10, 2018

The Applicant is the (check all that apply):
❑ Property Owner
❑ Lessee (Attach a copy of the lease agreement & complete Item 4.)
❑ Purchaser (Attach a copy of the pending sales agreement & complete Item 4.)
® Developer (Attach a copy of the development agreement & complete Item 4.)
4. If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization: Paul Niemyski
Signing Official & Title:Paul Niemyski, Owner
Street Address:6902 Lakeshore Drive
City: Dallas State:TX Zip:75214
Mailing Address (if applicable):
City:_
Phone:
Email:
State:
Fax: ( )
Zip:
5. The licensed Design Professional that will be retained for the duration of the project, who may provide
information on the Applicant's behalf, and who will prepare and certify the as -built package:
Consulting Engineer/Landscape Architect:Alan J. Crees
Consulting Firm: Municipal Engineering, Inc.
Mailing Address:820-B State Farm Road
City:Boone State:NC Zip:28607
Phone: (828 ) 262-1767 Fax: [phone]
Email: acrees(a)mesco.com
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name & Title:
Organization: _
Mailing Address:
City:_
Phone:
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ® Low Density
State:
Fax:
❑ High Density
Zip:
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
It will be conveyed in natural grass channels. The only storm drain pipes are cross culverts along the roads.
Sheet flow promoted.
3. Stormwater runoff from this project drains to the Watauga River basin(s).
4. Receiving water information if more than 3 receiving waters, provide additional information on an attached sheet):
Receiving
Water 1
Receiving
Water 2
Receiving
Water 3
Receiving Stream Name
Clarks Creek
Dutch Creek
Watauga
Stream Classification
C
C;Tr
B;Tr,HQW
Stream Index Number
8-12-2
8-12-(1.5)
8-(1)
Stormwater Fast Track ATC Application Form Page 4 of 10 Feb. 10, 2018

Project area and density information:
Total Property Area
478,737 sf
Total Surface Water Area
174 sf
Considered to include:
• the normal pool of impounded structures;
• the area between the banks of streams and rivers; and
• the area below the Normal High Water (NHM line or Mean High Water (MHW) line.
Total Coastal Wetlands Area
0 sf
Considered to include: coastal wetlands landward from the NHW (or MHW) line.
Total Project Area
478,563 sf
Excludes the surface water area and coastal wetland area identified above.
May or may not be the same as Property Area.
Built -Upon Area (BUA) associated with Existing Development
18887 sf
"Existing development" means those projects that are built or those projects that have established a
vested right under North Carolina law as of the effective date of the state stormwa ter program or
applicable local government ordinance to which the project is subject.
Proposed New BUA
35,496 sf
Includes proposed new BUA that is not associated with existing development.
"BUA" is defined in N.C.G.S. 143-214.7(b2). It includes, but is not limited to: buildings, roads, parking
areas, sidewalks, and some gravel areas. The design volume of SCMs must take into account the runoff
from build out from all surfaces draining to the SCM in accordance with 15A NCAC 02H .1050(1).
Project Density
w/Existing Development: Project Density = [New BUA]/[Total Project Area —Existing BUA] x 100 or
7.72
w/o Existing Development: Project Density = [New BUA]/Total Project Area] x 100
6. Anticipated construction start date Spring 2023
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
If `Yes,'see S.L. 2012-200, Part Vl: http://www.ncleg.net/Sessions/2011/Bills/Senate/PDF/S229v6.Pdf and
DEQ Stormwater Design Manual Chapter E-4 Airports.
8. For projects in Union County: Contact DEMLR Central Office Stormwater staff at 919-707-9200 to determine
if the project is located within a Threatened & Endangered Species watershed that may be subject to more
stringent stormwater requirements per 15A NCAC 02B .0600.
Stormwater Fast Track ATC Application Form Page 5 of 10 Feb. 10, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW). Only application packages that include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
Initials
1.
Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
714-e—_
Process "Authorization to Construct" (ATC) Permit Application Form.
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2.
Permit application processing fee of $505 payable to NCDEQ.
3.
Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving water
drains to Class SA waters within % mile of the project boundary, include the %2 mile radius
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575-foot
radius on the map.
4.
Two original signed hard copies and one electronic copy of a site plan depicting the boundary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
5.
Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
6.
A copy of the most current property deed. Deed book: 2197 Page No: 300
7.
[IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LLC): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. https://www.sosnc.gov/search/index/corp
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8.
[IF APPLICABLE] When the applicant is a Partnership or other person engaging in business under
an assumed name, attach a copy of the Certificate of Assumed Name.
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9.
[IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development agreement,
or other documents showing that the applicant has obtained legal rights to submit a stormwater
permit application within the proposed project area.
1, r
l 10.
[IF APPLICABLE] If modifying an existing permit for completed or partially completed projects, a copy
of the designer's certification.
Stormwater Fast Track ATC Application Form Page 6 of 10 Feb. 10, 2018

The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must sign and have
notarized the following guaranty: —('ree4vx s,,
1, (print or type name of Applicant/Financially Responsible Party) i L , t i , Loy e , Z-i— C
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that:
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
02H .1050 through .1062, to the best of my knowledge;
2. the completed design meets or will meet the MDC and that the percentage BLIA that is the basis for the
design shall not be exceeded, to the best of my knowledge; and
3. As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath I
agree to provide corrected information should there be any change in the information provided herein.
Type or prin me Title or Authority
Signature Date
1, IOW , a Notary Public for the State of NC , County
of do hereby certify that personally
appeared before me this tA day of and ac nowledge the due execution of
the application for a stormwater permit. Witness my hand and official seal,
f
Morgan A. Redmond
NOTARY PUBLIC
Watauga County
North Carolina
My Commission Expires November 6, 2026
SEAL
My commission expires ( ( L(,0 t l

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.5.
C�2e� , attest to the following:
1. This application has been reviewed by me and is accurate and complete, to the best of my knowledge;
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NCAC 02H
.1050 through .1062, as applicable;
3. The percentage built -upon area that is the basis for the design will not be exceeded; and
4. 1 have the expertise, education, and experience required to design the SCMs proposed in this
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 through .1062.
5. 1 will provide all documents and certified as -built plans in hard copy and electronic format related to
this permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a new
Applicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition, any person
who knowingly makes any false statement, representation, or certification in any application may be reported to
the appropriate professional licensing board.
Signatur Date: 2— 2-3
CAI/liii
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pFESS/0- 2�
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27044 —
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Stormwater Fast Track ATC Application Form Page 8 of 10 Feb. 10, 2018

1, (print or type name of theProperty Owner) '74,11 1-, (' , certify that I
own the pr, party identified n this permit application, and thus give permigsion to (print or type name of Applicant)
Xt-14- iI � MCA 114 t with (print or type name of Applicant's
organization) TnIS77 ff QL L ll<Z- ZJ e, to develop the project as
currently proposed. A copy of the lease agreement or pending property sales contract has been provided with the
submittal, which indicates the party responsible for the operation and maintenance of the stormwater system.
As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-21-,5.1 and may result in appropriate enforcement action including
the assessment of civil ties of up to f25,000 per day, pursuant to NCGS 143-215.6.
Signature:
Date: 2A, L40;2051
1, r awAdt) A. ke(-4CYO bnd" a Notary Public for the State of County
of 1A 111A I 1ar, do hereby certify that k� —1-hi.Lt L int, Lam. J personally
appeared before rithis day of rmwavj and acknowledge the due execution of
the application for a stormwater permit. Witness my hand and official seal,
Morgan A. Redmond
NOTARY PUBLIC
Watauga County
North Carolina
SEAL
My commission expires I 1 /0 b U