NCC221833_NOI Signed Certification_20220512

NCGO1 Notre of Intent (N®I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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 ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false 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 guilty 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):
M 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.
0 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.
0 I will abide by all conditions of the.NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part li (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that ail conditions of Part If of the
permit are met on the project at all times.
0 I hereby request coverage under the NCGO10000 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.
Project Name (must match Ala): The Grove
Specific Lot Numbers (must match Alb): 6,7,8,9,10&11
Permittee (must match Bl): Hughes Development, LLC
Legally Responsible Person (must match B2 & B3): Richard Stockett.
Title of Legally Responsible Person (must match 83b): manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-623-3404
re of Legally Responsible Person or Authorized individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 NCGO10000 permit.

F40RTH CAS OUNA
FAWronmrntu'l Qualify
J:, lVi=rE'� .�..ti�...,.-
A. Protect trformaflon I B. Perrnittee ln,orrnation f C. Site Contact inforri"iatiori I D. E&SC Plan
E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be iaintained 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 Article; or who falsities, 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 Article shall be guilty 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:
* 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 NO[ 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
inform Lion.
7k �' all r 1 n
v i ,rril� abide by a�� conditions of the N.,GQ E QQQQ Genera! Permit and the approved
Erosion and Sediment Control Plan.
1 hereby request coverage under the 114CG01 QOQQ 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: * � .- ► ne Legally Responsible Person named on this Notice of Intent
0 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,1tem (6) of that permit.
Signature` 1
Type Name* Richard Stockett
Title * Manager
Organization* regally Responsible Entity
Hughes Development LLC
Date * Date will be captured on form submission
I'm not a robot
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