10-1035-014ri .n ARC ITECT-,
J. Project Contact: INSTRUCTIONS —DEP FORM 62- 621300(4)(b)
NOTICE OF INTENT K. Project Contact's Phone No.: NOTICE OF INTENT (NOT) TO USE GENERIC PERMIT FOR S fORhIVt'ATER DISCIIARGF. FROM LARGF,
AND S14IALL CONSTRUCTION ACTIVITIES
TO USE L. Project Contact's Fax No.:
NVho Must File an NOT ?:
GENERIC PERMIT FOR STORMWATER M. Project Contact's E -mail Address:
FLOR A Federal law at 40 CFR Part 122 prohibits the point source discharge of pollutants, including the discharge of stormwater
DISCHARGE FROM LARGE AND SMALL IV. PROJECT /SITEACTMTY INFORMATION• associated with large construction activities as defined at 40 CFR 122 26(b)(14Xx) or small construction activities as
CONSTRUCTION ACTIVITIES defined at 40 CFR 122.26(b)(15), to waters of the United States without a National Pollutant Discharge Elimination System
(,NPDES) ermrt. Under the State of Florida's authority to administer the NODES stormwater program at 403.0$35 F.S.
p ty P >�'
(RULE 62- 621.300(4), F.A.C.) ❑Large Construction (Project will disturb five or more acres of land.) operators that have stormwater discharge associated with large or small construction activities to surface waters of the State,
including through a Municipal Separate Storm Sewer System (MS4), must obtain coverage either under a generic permit
��1� ❑
Small Construction (Project «iD disturb one or more acres but less than five acres of land.) issued pursuant to Chapter 62 -621, F.A.C., or an individual permit issued pursuant to Chapter 62 -620, F.A.C.
This Notice of Intent (NOI) form is to be completed and submitted to the Department before use of the Generic Permit for
Stormwater Discharge From Large and Small Construction Activities
in subsection G2 - 6
21.3
40(4), F.A.C. The
type of project or activity that qualifies for use of the generic permit, the conditions of the permit and additional
requirements to request coverage are specified in the generic permit document [DEP Document 62- 621.300(4)(3)]. The
appropriate generic permit fee, as specified in paragraph 62- 4.050(4)(d), F.A.C., shall be submitted with this NOI in
order to obtain permit coverage. Permit coverage will not be granted without submittal of the aopronriate generic
permit fee. You should familiarize yourself with the generic pennit document and the attached instructions before
completing this NOT f o rm Please p rin t or type information in the appropriate areas below.
I. IDENTIFICATION NUMBER: Project ID
H. APPLICANT INFORMATION:
A. Operator Marne:
B. Operator Status:
C. Address:
D. City:
E. State:
F. Zip Code:
G. Responsible Authority:
H. Responsible Authority's Phone No.:
I. Responsible Authority's Fax No.:
J. Responsible Authority's E -mail Address:
III. PROJECT /SITE LOCATION INFORMATION:
A. Project Name:
B. Project Address/Location.
C. City:
D. State:
E. Zip Code:
F. County:
G. Latitude: e ` " Longitude: ° ' "
H. Is the site located on Indian Country Lands? ❑ Yes ❑ Nro
I. Water Management District:
Page 1 of 5
DEP Fonn 62- 621.300(4)(b)
Effcctiw Februan 17.2009
B. Approximate total area of land disturbance from commencement through completion of construction: acres
Address in
Part IT above Address
...:S�F. � &wit <:> m Part III above Other address (specify
__...._........ ❑ I below
( Pe f3` )
D. SINTPP Address:
E. City: F. State: G. Zip Code:
II Cttt3lanlimd Start Date: Completion Date:
V. DISCHARGE INFORMATION:
A. MS4 Operator Name (if applicable):
B. Receiving Water Name:
VI. CERTIFICATION`:
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete.
I am aware that there are significant penalties for submitting false information, including the possibility of fine and
imprisonment for knowing violations.
Responsible Authority Signature:
Signatory requirements are contained in Rule 62- 620.305, F.A.G.
DEP Fom162- 621.300(4)(b)
Effective February 17, 2009
Items G. — J.: Provide the name, telephone and fax number (including area code) and E -mail address of the person
authorized to submit this NOI on behalf of the operator (e.g., Jane Smith, President of Smith Construction Company on
behalf of the operator, Smith Construction Company-, John Doe, Public Works Director on behalf of the operator, City of
Townsville; etc.). This should be the same personas indicated in the certification in Part VI.
Part III — Project /Site Location Information:
Items A. -- E.: Enter the official or legal name and complete street address, including city, state and zip code of the project.
Do not provide a P.O. Box number as the street address. If it lacks a street address, describe the project site location (e.g.,
intersection of State Road 1 and Smith Street).
tt_e_m F_: Enter the county in which the project is located.
Item G.: Enter the latitude and longitude, in degrees - minutes - seconds format, of the approximate center of the project.
Item H.: Indicate whether the project is located on Indian Country Lands.
Item I_: Enter the appropriate five or six letter code from the list below to indicate the Water Management District the
project is located within:
NtWF1VT%D] ° Northwest Florida Water Management District
SR1tqvll) = Suwannee River Water Management District
SFWMD = South Florida Water Management District
SWF VMD ° Southwest Florida Water Management District
SJRWIvID =St. John's River Water Management District
Items J. - M.: Give the name, telephone and fax number (including area code) and E -mail address of the project contact
person. The project contact is the person who is thoroughly familiar with the project, the facts reported in this NOI and who
can be contacted by the Department if necessary.
Part IV — Projectt'Site Activity Information:
Item A.: Check the appropriate box to indicate whether the project involves large construction activity or small construction
activity. Check one bog only.
"Large Construction Activity" means construction activity that results in the disturbance of five (5) or more acres of total
land area. Large construction activity also includes the disturbance of less than five acres of total land area that is part of a
larger common plan of development or that will ultimately disturb five acres or more.
"Small Construction Activity" means construction activity that results in the disturbance of equal to or greater than one (1)
acre and less than five (5) acres of total land area. Small construction activity also includes the disturbance of less than one
acre of total land area that is part of a larger common plan of development or sale that will ultimately disturb equal to or
greater than one acre and less than five acres.
Item B.: Provide the approximate total area of land disturbance, in acres, that the project will involve from commencement
of construction through completion.
Items C. - G.: Indicate the location where the Stormwater Pollution Prevention Plan (SWPPP) can be viewed. Provide the
address where the SWPPP can be viewed if other than as provided in Parts IT or III of the NOL Note that to be eligible for
coverage under the generic permit, the SNA'PPP must have been prepared prior to filing this NOI.
Item H.: Enter the estimated construction start and completion dates in the MMM/DD /YY format
Page 4of5
DEP Forn 62- 621.300(4)(b)
Effective February 17, 2009
Page 2 of 5
Date Signed:
Where to File NOI:
The Department encourages the electronic submission of NOls using the Department's Interactive Notice of Intent (iNOI)
available at http: / /ivww.dep. state .fl.us /water /stornlwateT /npdes /. As an alternative, NOIs may be submitted by paper copy to
the following address:
NPDES Stormwater Notices Center, MS 92510
Florida Department of Environmental Protection
2600 Blair Stone Road
Tallahassee, Florida 32399 -2400
Permit Fee:
Permit fees for large and small construction activities to be covered under the generic permit are specified in paragraph 62-
4.050(4)(d), F.A.C. The appropriate generic permit fee (either for large or small construction activities) must be submitted
along with the completed NOI in order to obtain coverage under the generic permit. Generic permit coverage will not be
granted without payment of the appropriate permit fee.
If the NOI is submitted electronically, the permit fee shall be paid on -line by credit card. If the NOI is submitted using a
paper copy, the permit fee shall be paid by either check or money order made payable to: "Florida Department of
Environmental Protection ".
Part I — Identification Number:
Enter the project's DEP identification number (generic permit coverage number) if known. If an TD number has not yet been
assigned to this project (i.e., if this is a new project), leave this item blank.
Part II — Applicant Information:
Item A.: Provide the legal name of the person, firm, contractor, public organization or other legal entity that owns or
operates the construction activity described in this NOI. The operator is the legal entity that has authority to control those
activities at the project necessary to ensure compliance with the terms and conditions of the generic pennit.
Item B.: Enter the appropriate one letter code from the list below to indicate the legal status of the operator:
F = Federal; S = State; P = Private; M = Public (other than federal or state); O = Other
Items C. —F.: Provide the complete mailing address of the operator, including city, state and zip code.
Page 3of5
DEP Form 62- 621.300(4)(b)
Effective February 17, 2009
Part V— Discharge Information:
To be covered under a CGP, the facility must have the potential to discharge stormwater associated with construction
activity to a MS4, a surface water body or both NOls submitted without discharge information cannot be processed.
Item A.: If stormwater from the project discharges to a municipal separate storm sewer system (MS4), enter the name of the
operator of the MS4 (e.g., City of Tallahassee MS4, Orange County MS4, FDOT District 5 MS4, etc.). If stormwater from
the project does not discharge to an MS4 but to surface waters of the State, leave this item blank or indicate "N /A" and skip
to Item B. of this part. Please note that if the project discharges stormwater to an MS4, you must proAde the MS4
operator with a copy of the completed NOT.
Item B.: If the project discharges stormwater to surface waters of the State, and not to an MS4, enter the name of the
receiving water body to which the stormwater is discharged. Please provide the first named water body to which the
stormwater from the project is discharged (e.g., Cypress Creek, Tampa Bay, unnamed ditch to St. Johns River, Tate's Hell
Swamp, etc.).
In certain cases, stormwater from the project will discharge to both an M94 and surface waters of the State. In this case,
complete both Item A. and Item B.
Part VI — Certification:
Type or print the name and official title of the Responsible Authority signing the certification. Please note that this must be
the same person indicated in Item II.G. as the Responsible Authority. Sign and date the certification.
Section 403.161, F.S., provides severe penalties for submitting false information on this application (NOI) or any reports or
records required by a permit There are both civil and criminal penalties, in addition to the revocation of permit coverage for
submitting false information.
Rule 62- 620.305, F.A.C., requires that the NOI and any reports required by the permit be signed as follows:
A. For a corporation, by a responsible corporate officer as described in Rule 62- 620.305, F.A.C.;
B. For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
C. For a municipality, state, federal or other public facility, by a principal executive officer or elected official.
Page 5 of 5
DEP Form 62- 621.300(4)(b)
Effective February 17. 2009
NOTES:
1. REFER TO DEP DOCUMENT NO. 62- 621— .300(400)a EFFECTIVE FEBRUARY 17,
2009 FOR GUIDELINES TO OBTAIN NOI TO USE GENERAL PERMIT FOR STORMWATER
DISCHARGE FROM LARGE AND SMALL CONSTRUCTION ACTIVITIES.
2. THE CONTRACTOR WILL BE RESPONSIBLE TO OBTAIN THE NPDES PERMIT FROM
THE FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION (FDEP).
3. THE EROSION AND SEDIMENT CONTROL PLAN SUBMITTED TO FDEP FOR THE
NPDES PERMIT SHALL CONFORM TO THE 2003 EPA CONSTRUCTION GENERAL PERMIT
REQUIREMENTS
4. FDOT INDEX #102 (SHEETS #1 & #2) OF THE 2010 DESIGN STANDARDS
BOOKLET ARE INCLUDED HERE BY REFERENCE AND SHALL CONTROL AND IF MORE
STRINGENT THAN THE DETAILS SHOWN.
BERMELLO AJAMIL & PARTNERS, INC.
- ArcHted"Ure P-ngiheering Planning
.Interior Design t andacape Architecture
2601 South Bayshore Drive 10th Floor
Miami, Florida 33133
(305) 859 -2050 Fax (305) 860 -3700
PLANNING ARCHITECT:
31310
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FN
WILMOT SANZ
A R C H I T E C T U R E
P L A N N I N G
18310 Montgomery tillage Avenue
Gaithersburg, Maryland 20879
301- 590 -2900 (Fax) 301- 590 -8150
STRUCTURAL ENGINEER:
- 2b�f]L��INE�iNE�ts
❑RAMON R. DONNELL P.E. 0011690
1."1\1'/5 -. F. uc TUR AL
CPEDRO J. DUQUESNE P.E. 0022764
❑AIDA M. ALBAISA P.E. 045130
r�t,n�/5 e,,4541n
�_ 493p S.W. 74th T. MIAMI, FLORIDA 3315
t305I 666 -0711 FAX 666 -5259
rA OF FLORDA — A0IHOWATION No. 1308
MEP ENGINEER:
2121 Ponce de Leon Blvd., Suite 350
Coral Gables, FL 33134
Rofessiond Car6u NErg.. phone: 305.569.1692
fax 305.569.1693
Dallas . Houston . Nashville . Miami . Richmond
Austin . Denver . Phoenix . Washington D.C.
ccrd project number. 405112038
EB00007658
IT CONSULTANT:
GENE BURTON & ASSOCIATES
1893Gczn1OcorgcPaamDdvc 584owcatl- 20, Suite 150
Franklin. Te in x 37067 Artinglml, Texas 76017
Pkorte:615.376.3100 11ace 817-563.2486
F4x.615.376.3114 Far: 817.563.2753
WrAxtrc wsrw.gbeim-com
Medical Equil7mart and Communications Plunne s
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p • „g, `°
JACK YOUNG, P E.
FLORIDA LICENSE #45646
F-PERMIT"S'ET
PROJECT NAME:
SMH- CLINICAL EXPANSION
FOUNDATION PACKAGE
PHASE 11
PROJECT ADDRESS:
7400 S.W. 62nd Ave.
South Miami, Florida 33143
KEY PLAN
COMM. NO. 40051.100
SCALE:
DATE: 07-09 -2010
DRAWN:
CHECKED: JY
CADD FILE: H:INSTITUTIONAL
DRAWING TITLE:
NOI TO USE
GENERAL PERMIT FOR
STORMWATER DISCHARGE
SHEET NO.