NCC224019_NOI Signed Certification_20221206

Nla01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, stair and upload to the electronic NaI.
Then, mail the anginal farm to the NC DENT LR Storrnwater Program (with 100 check if paying by check) at:
Division of Energy, Mineral & Land Re5ource5 Storm Ater Program
512 N. Salisbury Street, 6,h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 2769-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE,
TIDE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL 51GNATURE (NOT DIGITAL) [40 CPR 122.22]
Per NC Generuf Statute 143-215_68 (i), uny person who knowingly makes any false statement, representation, or
certification in any application, record, rep ort, plat?, or o ther document filed or required to be maintained under this
Article or a rule lmpiernmenting this A rticle ... shall be guilty of a Class 2 misdemeanor which may include o fire not to
exceed tern 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.
0 The Ofcrmation submitted 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 responsibJe for
gathering the informatlon.
[] I will abide by all conditions of the NCG010000 General Permit and the approved Erasion and Sediment Control
Plan_
0 If the approved Erosion and 5e0iment Control Plan is not corn pIiant with Park JI (Stormwater PoAution
Prevention Plan) of the NC6010000 General Permik. I will nonetheless ensure that all conditions of Park II of the
permit are met on the project at all times.
M I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
pernnit will constitute the permit req u irernents for the discharge{s) and is enforceable irr the same manner as an
individual permit,
Project Name Imust match Ala)_1 ood piing Suites
Specific Lot Numbers (must motc'h Alb), Lot 1 M 6 4-74
Permittee (must match B1)• Gold Coast Properties N C 1, LL
Legally Responsible Person (must match 92 & 83)- Voronica Garcia
Title of Legally Responsible Person (must match 83b); President & Chief Operating Officer
Name & Title of Sig
Differs from Legall}
}
Phone N
Authorize Individual
)n5ib n:
Responsible Person or Authorized Individual
10/20/22
Date
* tAfPoRTANTNOTE.
such as a president
Item (6) of the N (
m ust be signed by a responsible corporate officer that owns or operates the construction activity,
treasurer, or vice president, or a manager that is authorized in accordance with Part IV Section 8,
Permit