HomeMy WebLinkAboutNCC211745_NOI Signed Certification_20210323NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215,,6B (i),, 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 ...shall be quiltv of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
� 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.
� The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person CD persons who manage the system, or those persons directly responsible for
gathering the information.
� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
:K1 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit. I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit willconstitute the permit requirements for the discharge(s)andisenforceableinthesa e
individual permit.
Name of Project (must match Ala): Ananda at Bella Casa
Specific Lot Numbers (must match Alb): 1
2, 3 & 4
Legally Responsible Organizational Entity (must match Bl): Faithwill Homes, LLC
Legally Responsible Person (must match 82 & B3): Sanjay Khazanchi*
Title of Legally Responsible Person (must match B3b): Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
PhoneNumber: 917m=371IIIIIIIIIm7175
ON 100 /VVI
rN V4 0 04,
Signature of Legally R..;M�fsi le Person or Authorized Individual Date
* IMPORTANTNOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretory, treasurer, or vice president, or a manager that is authorized in nccordance with Part IV, Section B.,
item (6) of the NCGO10000 permit.