NCC231514_NOI Signed Certification_20230518

NC 01 Notice of Intent (NOI) Certificatio i Form
Directions:
Print this form,complete, scan and upload to the electronic NOI.
Then, mail the original fo m to the NC DEMLR Stormwater Program (with$100 check if paying by check) at:
Divisi n 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 FOR OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE 1 ORM YOU MAIL MU T BE COMPLETED WITH AN ORIGINAL.SIGNATURE(NOT€IGITAL) [40 CFR 122.22)
Per NC General Statute 143-215.68(I), any person who knowingly makes any false statement,representation, or
certification in any application, cord,report, plan,or other document filed or required to be maintained under this
Article or a rule implementing t is Article. ..shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($1 ,000).
Under penalty of law, I certify t at(check all boxes to indicate your agreement):
Er I am the person responsible for the construction activities of this project,fo'satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
The information submit'ed in this NO1 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.
LdiI will abide by all conditi ns of the NCG010000 General Permit and the app oved Erosion and Sediment Control
Plan.
1211. If the approved Erosion nd Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the CG010000 General Permit,1 will nonetheless ensure that all conditions of Part 11 of the
Er/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 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): 39 L\ odpy r
Specific Lot Numbers(must latch Alb): en
Permittee(must match 81): ,h(litu bY\ �Q
Legally Responsible Person (Must match B2& B3): ,5hQ z-wT utyl_QA
Title of Legally Responsible Pierson (must match B3b): 3� �,/� vQn.
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: .0 .� —'CI 1&.. a 51
Signet.r= .f I,� • Person or Authorized Individual Date �
* 1MPO' • , 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 NCG010000 permit.