NCC221072_NOI Signed Certification_20220316

NCGO1 Notice of Intent (N01) 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 Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT
MAIL
THIS
FORM
OR
PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM
YOU
MAIL
MUST
BE
COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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 ($10,000)1.
Under penalty of law, 1 certify that (check all boxes to indicate your agreement):
Q✓ 1 am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for anv civil or criminal penalties incurred due to violations of this permit -
The information submit-ted 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 inf o r m2 -tion.
✓� I will abide by all conditions or the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
[]✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plank or' the NCGO10000 General Permit, I will nonetheless ensurF that all conditions of Part- II of the
permit are met on one project at al( times.
Q✓ I hereby requesL coverage under she NCGO10000 General Permit and understand that coverage under this
permit will constitute she permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permi�.
Project Name (must march Ala): 1043 Trumpet Vine New Construction
Specific Lot Numbers (must matcAAlb): 38
Permittee (must march 131): F7 Development Inc
Legally Responsible Person (must match B2 & B3): James Montague
Title of Legally Responsible Person (must match B3b): President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-796-2546
Signatu� of Legally Responsible Perso
or Authorized Individual
2/2/20
* IMPORTANTdOTE.- Thisform must be signed by a responsible corporate officer that otivns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager thnr is authorized in accordance with Part 1V Section S.,
Item (6) of the NCGO10000 permit.