NCC232847_NOI Signed Certification_20230920

NCGO1 Notice of Intent (NO
I) Certification Form
Print this form, complete, scDaln and upload
Then, mail the original form to the NC DEMLR Stormwater Program
I;Y, •Mineral & Land Resources StoVrmwaterOPro rk if paying by check) at:
512 N. Salisbury Street, 6th Floor(Office 640K) gam
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT
ACCEPTED AS COMPLETE.
i an (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.6B
(), y person who knowingly makes any certification in any application, record, report, plan, or other document filed orarequired t lse ebe�maintainedtund ion, or
Article or a rule implementing this Article . r this
. . 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):
�]✓ 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.
✓Q 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.
✓0 I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
ElIf the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
and verage under this
E/ I hereby request coverage under the NCG010000 General Perrme s andnsd erstand enforceable that c nothe same manner as an
permit will constitute the permit requirements for the discha g ( )
individual permit.
Project Name (must match Ala): TanglewOOd 3
Specific Lot Numbers (must match Alb): 1-68
Permittee (must match 81): Bobby Hilgoe
(must match 82 & 83):
Legally Responsible Person Bobby Hilgoe
Title of Legally Respons
ible Person (must match B3b):• Market Partner
Print Name & Title of Signed ifAeShons b e Person:
Individual Differs from Legally R p
Phone Number: 919-669-4057 / 0n :uthorized
Individual
ID.
Legally sp officer that owns or operates the construct10Sect'on B,
Signature onsible corporateis authorized in accordance with Port i�,
be signed by a resp
This form mustresident, or a manager that
* impORTANT NOTE. treasurer, or vice p
resident, secretary.
such asap CG010000 permit.
Item (6) of the N