NCC223770_NOI Signed Certification_20221107

NCG01 Notic—e of Intent (1401) Certification Form
Print this form, complete, scan and upload tothe electronic N0L
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division of Energy, Mineral Q Land Resources StonnwaterProgram
S12N.Salisbury Street, 6mFloor (Office 64DK)
1612Mail Service Center
Raleigh, NC27699-16l2
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Per NC General Statute143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certif7urtion/nany application, record, report, plan, o/other dncumentfiledorrequired tobemaintained under this
Article nrorule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$1[\0OD/.
Under penalty cflaw, | certify that (check all boxes taindicate your :
[v-1 |amthe person responsible for the construction activities ofthis project, for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[�l The information submitted in this N0 is, tothe best ofnv/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.
[D | will abide byall conditions ofthe and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe project atall times.
[�l | hereby request coverage under the NCGO10000 General Permit and unde/�an6that coverage under th�
penn�vviUconstbutethe permit requinementsfor the disdharge(s)and isenforceable inthe same manner asan
individual permit.
Project Name (must match Ala): BVlNno
Specific Lot Numbers (must match Alb):
Pennittee(must match 81):Terra Nova Legacy, LLC
Legally Responsible Person (must match B2 & B3): Monica Herrera-Rangel
Title of Legally Responsible Person (must match B3b): Managing Member
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
���-�5�-��4Ql
Phone Number: /
Monica Herrera-Rangel/
Signature of Legally Respon4s)ble Pe­rso-�n or ndividua| Date
*IMPORTANTNOTE. This form must be signed bynresponsible corporate officer that owns moperates the construction activity,
such osopresident, secretary, treasurer, orvice president, o/omanager that isauthorized /noccondoncewithPor IV, Section f\