NCC222542_NOI Signed Certification_20220715

NCC01 Notice of Intent (C OI) Certification Form
IDirectians:
Print this farm, Complete, scan and upload to the electronic NOI.
`hen, mail the original form to the NC OEMLR Stormwater Program (with 5 100 cheek if paying by check) at'
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, fit^ Floor (Office 640K)
1612 Mai Service Center
Raleigh, NC 27G99-1512
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 DIGITALI [40 CFR 122.221
Per NC General Statute 143-215,58 (i), any person who knowingly makes any false statement, representoNon, or
Certlfkat on in ony application, record, report, plarp, or o ther document fined or required to be maintained wader this
Article or a rule implementing this Article ... shall be qufity 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 far 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 N01 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.
❑, I will abide by all conditions of the NCG010000 Genera I Permit and the approved Erasion and Sediment Control
Plan,
Q If the approved Erosion and Sediment Control Plan is not cornpllant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 Genefal Permit, I will nonetheless ensure that all conditions of Pa rt I I of the
permit are met on the project at all times.
J I hereby request cave rage under the NCGO10000 (general Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges} and is enforceable in the same manner as a n
individual permit.
Project Name (must match Ala). The Fiats at Statesviilie
Sperific Lot Numbers (must motch Alb)'
Perm ittee (must match 81 }' More Apartments, LL
Legally Responsihle Person (must match 82 & 83). By Josh Lipsky
Title ❑f LeaaIN Responsible Person (must match 83b]: its: Managing Member
Name & Title of Signed if authorized 1ndiviauaI
Differs from Legally Res oonslble Person:
Phone plumber: 770-318-9967
Sign atu bTLegaIl Responsd6@-Rer n or Authorized Individual
Date
* 1114PORTA NT NOTE. This form must be signed by o respansWe corporate officer the t owns or operates the construction activity,
such 0s o president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Fart fV, Section 8,
!tern (61 of the NCG010= permit_