NCC221651_NOI Signed Certification_20220504

NCG01 Notice of Intent IN011) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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, 6,h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
UNTILJ 7 5"M - R F 2.1% V MEN 'OUR APPLIC-A', ION HAS BEEN ACCEP17
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]4 T'A '03ui "MA"o,. "LRAI Ll KW' a­OMPLETEE D WMH AN OROGINAL SIGNATV RE 5N!Q'
Per NC General Statute 143-215,6B (i), any person who knowingly makes any fulse statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . o shall be guilty of a Class 2 misdemeanor which may include ofine 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.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and conriplete
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 NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
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 H of the
permit are met on the project at all times.
I hereby request coverage Linder the KG010000 General Permit and understand that coverage under thlf,
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): Buies Creek Townhomes
Specific Lot Numbers (must match Alb): N/A . .... .
Permittee (must match Bl): Stancil Builders, Inc
Legally Responsible Person (must match B2& .3): Freddie Stancil . ... ....... . .... .....
. . . .... . .. . . ..........
-Title of Legally Responsible Person (must match B3b)- President
Name & Title of Signed if Authorized Individual N/A
Differs from Legally Responsible Person:
Phonem-Aer: 919-639-2073
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'F,�tnsible r�rson or uthorized Individual
m4poRTANTNOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Par., IV, Section B,
Item (6) of the NCG01 0000 permit.