NCC222915_NOI Signed Certification_20220815

NCGO1 Notice of intent (NDi) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI in b ciieck� at:
ith
Then, marl the original farm to the NC �NMeRaI & Land Resources Storam Wmwate�Programcheck if paY 9 y
Division of Energy,
512 N. Salisbury Street, &-, Floor (Mce 644K)
1512 Mall Service Center
Raleigh, IBC 27699-1612
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS 13EEN ACCEPTED AS COMPLETE.
THE FORM YOU MAILAAUST BE COMPLH-ED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
Per NC General Stutute 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};
am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and far any civil or criminal penalties incurred due to violation; of this permit.
✓(,/ The information submitted in this POI i,, to the best of my knowledge and belief, true, accurate, and complete
bated on my inquiry of the person ar pers0ns who manage the system, or those persons directly responsible for
gathering the information,
0 I will abide by all conditions of the NCG010000 General_permit and the approved Erosion and sediment Control
Plan.
0 if the approved Erosion and Sedirnent Control Pia Is not compliant with fart II (Starmvrater Pollution
Prevention Plan} of the NCGO10000 General Permit, f will oanetheless ensure that all conditions of Part II 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 !or the d;scharge(sl and is enforceable in the same manner as an
individual permit,
Project Name (must morch AID): Creedmoor Manor 8
Specific Lot Numbers (roust motchAlb j: Lot 6
Perrnittee iniust match $1): Gray Line Buiiders, LLG
Legally Responsible Person (must match L22 & 8.3y: Justin Patsey
Title of Legally Responsible Person (musr match 83by: Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person_
Phone Number- 919-669-2084
(1, L- � L-�4� 8/1 1120.ia-
Signatu re caegally Responsible PEriln or Authorized Individual slate
' WPORWIT N OTE: This form must be signed by a resporl$ibit corporate Officer that awns or operates the construction activity,
such as a oresident srcretory, treasurer, Or vice president, or a man oget that is aull+OMed in occordunce with Putt IV, Section 8,
Rem (5j of the NC6010000 permit_