NCC232223_NOI Signed Certification_20230727

NCG01 Notice of Intent (1401) Certification Form
. Directions:
Print this form, complete,scan and upload to the electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral& Land ResourcesStormxvater Program
S12N1. Salisbury Street,6m Floor(Office 64OK)
1612 Mail Service Center
Raleigh, N[2769Q'1Gl2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
��THE FORM YOU �'MUST BE COMPLETED - -
- _ — _- ' - _- _-_-- - _- _ 4-
Per N[General Statute 243'215.68(i), any person who knowingly makes onyƒobe statement, representation, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article oro rule implementing this Article. . . shall be guilty o/o Class J misdemeanor which may include o fine not to
exceed ten thousand dollars/$2[l000/.
Under penalty of law, | certify that(check all boxes twindicate your agreement):
|v| 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.
rv-1 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.
F�l I will abide by all conditions of the NCG01.0000 General Permit and the approved Erosion and Sediment Control
Plan.
FV-1 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times,
[v-1 I hereby request coverage under the NCGO10000 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 A1o): |DD8S Residence - B8[C0
Specific Lot Numbers(must match A2b): LOt4. MODVOOUSk Subdivision
Permittee(must match 81): James B. |OO8S
Legally Responsible Person (must match 82& B3): James B. I DOeS
Title of Legally Responsible Person (must match 83b): Owner/Trustee
Print Name&Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone 2
7/24/2U
Sign atu eP�sonor Authorized Individual Date
* 0NPORT4NTA(O/re (ega
fonnmustbesk7ocdbyonesponsib/ecnnooroteo/ficerthotownsnropenrtestheconstroctivnoctivitK
such as a president,secretary, treasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(Wuf the NC5010UDOpermit.