NCC211361_NOI Signed Certification_20210308

NCG01 Notice of Intent (N00 Certificaticn Farm
Directions.
PTint t1%farm, complete, scan -arid upload iu l'he eIectror ic.N01.
Then, mail the original form to tha Nc DE M LR StorrnWater Program Iwi#h . 100 ch-2Ck ifpaVing by check) at-
DivisioP of Enemy, NA neriI & Land Resourr:es Storrnwater Prugrarn
512 N. Salisbury Street, 60- Floor (Off i-ce 64DK)
1612 Moil Service Center
Raieigh, NC 27699,1612
DO NOT MAIL THM FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per' ?VC Gerreraii StatutE 143-22-5_6B ({), urrp Person who kncwirgfy makes any false starerrrent, re�rr�serMtoi i(�r�, or
e rtrfi Iran fry a.9y app0cction, (ecord, reparl, plan, or other documr ,rrt filed or regurred Co be maintoined under Chj�
Aor a rule irt-rp)errmenfirrg this Article _ _ . shOd be guilty of 0 Class 2 misdemecwx which may irrcfude a fine nat ro
-exceed {en thousand doifors ( JOr ),
Undef penalty of law, I certify that .check a1f Ibokesto indicate Your agreementjl=
I am the person respvnsibic for the construction activities of this projecT, for satisfying th4 rcquiremQrts of this
Permit, and for any civil orerirrrinaI penalties incurred due iD +violations of this permit.
Tfie informaticin submhted in this NO is, to the best of my knowledgc and belief, true, accurate, and complete
based on rnV inr4uiry of the pef- 4nn or persons vvho fnanap�- tlTe system, or those pe,•sons directiy re-pan-'ible #or
gathering the inform.ition,
LJ I will ohide by all cor.ditiom, of the NCG3010000 Ge.noral Nrimit and -hc appro-ved Erosion and SedirTsent-Co ntrol
Pla n. .
If the approvoid Erosion and Sediment Cont Plan is rtot compliant with Part II (Storm water PeII ution
pflcventio,i Plan) of the INCGO100W General Pcrmitr I will nonpthoIcss ensure that all conditions of Part I I of the
permit are met on the project at all tirmes. '-
I hereby request caverap under the NCGD1DOOO General Permit paid understand #fat coverage under this
permit will constitute the permit: regWrem ents for lire discharges) at)d is enforneable in the sa me. manner as are
-ndividual permit_
Narne of Project (must matchA1a):
specific Lot Numbers must match AIb)=
Legally Responsible OrganiWiopaj Entity [must mo ch 01 ellv
-Legally. Rc5pens+e Person muse match &2 & i3.3): iyl e lar• -c C - 4Z1 os.
Tit It of Legally Responsible Person {must match 0.3b):
Name & Title of Signed if Authorimd Individual
Differs from Legally Responsible Person:
Phone Num
qty 3 9 J x .
of Legally Responsffile Person or Authorized Irdiuidual
" aMJ?]rA VrNOTE: T7r�; fofm rrx si ✓ ,i rked by d resporrsibte rvrpor�t of fiver t�rr}[ wl�s or perate3 the eonstFu[ rT (!C[r�rrFy.
suety as p presrderrr, wf'rc WY, t?*0$urer, or urce presideat or a rnorrager that is authorfzed in =ordance with Part IV, Section 6,
Item f.Gj of the NC663 Perry &