NCC201174_NOI Signed Certification_20200324

NC 01 Notice of Intent (NOI) Certification Form
Di rection s. -
Print this fom, corrtplite, scan and upload to the e1e ionic NO I_
I hen, mail the origi na I form to the MC l]EMlR Stormwater Prr g"m [with $100 died if poy+irrrq Syr ctreck) at;
Divf si on of Energy, Min-eral &. Land Resources Stormwa6er Program
512 N. Salisbu ryr Strapt, 15�- Floor (Crffi-e -6Kj
1612 Mai I Service Center
Raleigh, NC 276 1612
CEO NOT MAI L TH IS FORM 0 R PAYM ENT U N TI L YOU R APPLICATION HAS B E EMI
REVIEWED AND AOCEPTED AS COMPLETE
Per NC General Stotute 143-215.6& (i), any pL-rson w hD knowingly rr okes ort r false stutenviltl repres-eww or?,
or certif. cation in any apoicatron, record, report ,plan, or other document films cr r u rid to be rvjrr[�jrrie+d
imder rhrs Ar r eie or a rufe rmpt-vrnerttiaq [Firs Article - . , shai•1 be gurity of a Mass 2 misdemeorror wich may
indade zifene riot to exceed ren thous -and da Pars (51-0,6W)-
Under penalty of law, I vertu -that (died« all byes to indicate your agreement):
I am th e person respor►stbie for the corrstructlon actkiti-es of this projcck, for satisfwi ng the
requirements of this perm its a nd fnr a ny civil -or crlml no I penaides Pourred d ue to w i6ation s 4.rf thin.
permit.
3Z The iOor+rnation 5uhrn ixted in this NOS is, to the best of my knowledge and beli ef, t rue, aceu rate, and
complete ha sed an my inqu iry of the pargan or persons who manage the -5y:�tem, or th cue persons
directly responsible far pthering the information.
I wi II e bidr by all v ndi lions o f the NGGO1100M -Grairra I Prrm i and the approved Erosion and
5edi mf,.rrtr [:nntml Plan.
fib it the approved Lrosion and 5edimem c:onmA P;;n is not aornlAam v6th Part II �Storrftwate r Poll utiu n
Preverytiop PI an) of the Nc ()XGQ70 Gen era] Permit, I wi II nor th eless ens-ure than all conditions of
Part I I of the permit are rnEA an the proj.ett at all times,
7. 1 hereby request coverage under the HCGQ1XX General Perm it and un d errand that rowerage under
this perm i# will constitLrte the permit requirements for the discha rge(s) and is enarceable in the
same manner as an individual permit.
W irw. t%f Frojeet! 1 G' C
Legal Iw
Titl-e -of D
�� I 'T f A� � 7 -W , _
"SI n xtum: Date:
"Print Narne a n- : rJ * d ej Aa zed
irrdrvr ��r�l Diff ,�s from Pfrrrrfmpnt_ �, c ; � ✓
* Or1 FORTANT NOTE-- Thas}iorrrr must be signed by o responsibfe corporate officer that owns or apErQres the
Lur?6,ructiort mtrwity, such as a p ssidreoit secrewry, treasure.-. or vice president, or a manager that is
au4.h r'zed in oecofdonce wkh port V, S:Pct+o+ B, ,tern (6j of tyre N=IWOO yerrmk-
nor Mare enfivmgtron on signara y requir,emen s, see Part W, 5,or[ron E, Tern (h) of the NC601 Ob permit.