NCC232012_NOI Signed Certification_20230630

�J���"�1 ��otice *f Intent �����1) �e ^������K�� ����
Directions:
Print this form, complete, scan and upload tu the electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division uf Energy, Mineral & Land Resources StormwaterProgram
5IZN.Salisbury Street, 6,^ Floor(Office 64UK)
1612 Mail Service Center
Raleigh, N[%7699'16l2
DO NOT MAIL TFi'--' FORA60 OR PAYNIENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS CU� PLETE.
THE FORM YOU MAIL MUST QE—OKnPLETED WITH AN ORIGINAL
'SIGNATURE(NOT DIGITAL) [4OFR1I2.J2]
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article . . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars/$l<l0D0/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[71 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 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.
[�| I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
[7l If the approved Erosion and Sediment Control Plan is not compliant with Part || (Stornnvvute/ Pollution
� Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met onthe 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 A2o): The Grove at Gin Branch (Johnston)
Specific Lot Numbers(nnust/notchA2b): 1-31. 41-47 & 53-78
Permittee (must match 82): W4@tt8Dly HOnles, LLC
Legally Responsible Person (must match 82& 83): George Young
Title of Legally Responsible Person (must match B3b): Vice President of Land Acquisition
Print Name &Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 8196258546
'
��.Z�
�u ofLe�a||yR�spo�sib|ePemonorAuthurized /ndividua| Date
_ /
* IMPORTANT NOTE: Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such cis o president,secretary, treasurer,nr vice president, oro manager that is authorized in accordance with Part/K Section B,
Item(6)nf the N[GO10DD0permit.