NCC222823_NOI Signed Certification_20220811

Directions:
Print this form, complete scan and upload tothe electnonicN[U.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by checf<) at:
Division nfEnergy, Mineral & Land Resources 3tnrmwaterProgram
5I2N.Salisbury Street, 6^Floor (Office 640K)
1G1JMail Service Center
Raleigh, NC 27699-1612
00NOT MAIL THIS FORM ORPAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
Per �General Statute 143-215.6B (i), any person who knowingly makes onyfalse statement, representation, or
certification in any application, record, report, plan, mother dommentfiledmrequired to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include afine not to
exceed ten thousand dollars /$1(lD00/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
|amthe person responsible for the construction activities ofthis project, for satisfying the oequirennemtsofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit,
[�] 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,
c� | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Ft/1 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions nfPart Uo|the
permit are met on the project at all times.
�� | hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharQe(s)and isenforceable inthe same manner asan
individual permit.
—Project Name (must match Ala): Timber Ridge Lot 11
cific Lot Numbers (must match Alb):
Permittee (must match Bl): |S&SFamily Limited P@rtOe
—LegallyRichG0jSk8ff
Title of Legally ResponsibleProject Manager
Name 8/Title nfSigned if Authorized Individual
—Differs from |
Phone Number: 704.663.1563
Signature of Legally'W606-hsible Person or Authorized Individual Date
*VmPORTAm7IVOTE/This form must hosigned byoresponsible corporate officer that owns moperates the construction activity,
such 000president, secretary, treasurer, o/vice president, oromanager that isauthorized /naccordance with Port IV, section f\
Item (Qofthe NCGO 0000penn/t.