NCC223091_NOI Signed Certification_20220901

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form,,-omplete, scan and upload to the electronic NO).
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 NI Salisbury Street, 61h 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 DIGfTAQ [40 CFR 122.22]
Per NC General Statute 143-215.68 (I), any person who knowingly makes any false 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.. shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000J.
Under penalty of law, I certify that (check al� boxes to indicate your agreement):
O✓ I am the person responsible for the
permit, and for any civil or criminal
Q✓ The information submitted in this N,
based on my inquiry of the person o
gathering the information.
21 1 will abide by all conditions of the N
Plan.
)nstruction activities of this project, for satisfying the requirements of this
=nalties incurred due to violations of this permit.
is, to the best of my knowledge and belief, true, accurate, and complete
persons who manage the system, or those persons directly responsible for
and the approved Erosion and Sediment Control
O✓ if the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCG010000General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all t mes.
0✓ 1 hereby request coverage under the NCGO10000 General Permit and understand that coverage underthis
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): The A
Specific Lot Numbers (must match Alb):
Permittee (must match B1): Delray Ventures, LLC
Legally Responsible Person (must match B� &
Title of Legally Responsible Person (must r
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-496-9821 - $03
re of Legally
Daniel A. Jimenez
13—µZGt8
ible POson
Authorized Individual
SS 3o Z
Date
* IMPORTANT NOTE 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) resident, or a manager that is authorized in accordance with Part IV, Section B,
item (6) of the NCGO10000 permit.