NCC221093_NOI Signed Certification_20220324

NCGO1 Notice of intent (N01) Certification Form
Directions:
Pant this dorm, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check ifpaying 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.
THEFORKYOU.MAIL MUST 8E Ca1VIPtETEd WITKAN"ORIGINAL SIGNATURE'..(NOT DIGITAL) [4Q CFR 122.22]
Per !VC Genera! Statute 143-215.6B (i), any person who knowingly makes any#alse statement, representativn, or
certification in any appircafian, record, report, plan, or other documentfiled or rewired to be maintained under this
Article or a rule implementing this Article ... steall be guilty o, f a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,daD).
Under penalty of law., i certify that (check all boxes to ind*1cate 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.
The information submitted in this NO] 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 NCG010000 General Permit and the approved Erosion and Sediment Contra!
Plan.
[]✓ If the approved erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plank of the NCGO10000 General Permit t will nonetheless insure that all conditions of Part 11 of the
permit are met an the project at all times.
Q I hereby request coverage under the NCGO10000 General Perm -it 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 Ala). 5221 Steam Bank
.14
Specific Lot N umbers (must match Al-b).
� !•■ ■ ■ ■IYIYi 1 iY■i_Y �i i
Permittee (must match
1•11 1_Yggiii�i�i 1 1�1__•Y•i�W_■i.iY•i
Bl): Perry Properties & Development, Inc.
•� 1 r■ 1 A A ■ ■ ■ 1 1 1■■ IY Y i 4Y IiWrYftir V r �� 1 A��1_■■_1•Y�.•HY.•.•Y_•i.■!!.l��■�!_���� Legally RePerson (must match B2 & B3.)o
Title of Legally Responsible Person (must match B36): President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-868-0742
ti
Signature of E.e�aily Rensibl� Person �r7�horized Individual
Date
IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such os a president, secretary, treasurer, or vice president, or a manager that " out ri in accordance with Part f
Item (6) of the NCGOI0000permrt.