NCC230080_NOI Signed Certification_20230112

NCGO1 Nc
I
I
of Intent (Nbi) Cer
Directions:
:ion Form
Print this for , complete, scan and 'uploadd to the electronic NOI.
Then, mail the original form to th NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resou Ices Stormwater Program
51 N. Salisbury Street, 6t, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 276994612
DO NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR .�PPLloATION HAS BEEN ACCEPTED AS COMPLETE.
Per NC General Statute 143-215.6E (i), a person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other do,cument 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 ($10,000).
Under penalty of law, I certify that (chec:he
all boxes to indicate your agreement):
I am the person responsible for construction activity es of this project, for satisfying the requirements of this
permit, and for any civil or crimi ial penalties incurred due to violations of this permit.
ET-I'The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the pers n or persons who manage the system, or those persons directly responsible for
gathering the information.
Q I will abide by all conditions of the NCGO10000 Genera Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not co{ pliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure thatall conditions of Part II of the
permit are.met on the project at all times. i
hereby request coverage underr the NCG010000 General Pormit and understand that coverage under this
permit will constitute the permit requirements for the �dischlarge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): LO 7 Enchanted Oaks
Specific Lot Numbers (must match.A2b): 7
Permittee (must match 81);
Bent Leaf Development
Legally Responsible Person (mustm�tch B2 & 83): Carl Klger
Title of Legally Responsible Person (must match 83b): Partiner
i
Name & Title of Signed if.Authorized Individual
Differs from Legally Responsible. Per on:
Phone Number: 919-522-6281
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SignatureVLegly esp nsible Person or Authorized I
IMPORTANTNOTE:m must be signed by a responsible corpora
such as a president, secretary, treasurer, or vice president; or a m.anag
Item.(6) of the NCGo10000 permit.
'I
J
-V
ividual bate
officer that owns or operates the construction activity,
that is authorized in accordance with Part IV, Section D,
a