NCC230610_NOI Signed Certification_20230307

N GO1 Notice of Intent (N01) Certificatllon Form
Oirecticns:
P ri nt th is f o rm, com p lete, scan a nd upload to th a ele ctron is NO 1.
Then, mail tyre original form, to tale NC DE 1LR Storrnwater Program (vvith 100 check if paying by check) at:
Division of Energy, MineraI & Land Resources Stormwaxer Program
512 N. Sal i sb u ry Street, 6L?, Floor (0 ff ice 640K )
1612 Mail Servic-e Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 14-3-215, 6E (i), coy person who knowingly mokes anyfalse statement, representor on, or
C,-rtifocation in arty Gpplication, record, report plan, or other docriment fried or regi red to be rr aintafned under this
Article or a rake implementing this Article , , shall be guilty of o Cla5s2 m sdemeorror which may fnclude u fin enot to
exceed tern thouscnd dollars f 10, 000).
U n de r pe na I ty of law, I ce r tify th at (.cheek a 11 boxes to i nd irate -your a greement)
am the person responsible for the construction acti-cities of this project, for satisfying the requirements of this
permit, and for ariy civil or criminal penalties incurred due to violations of this permit_
The information submitted in this N01 is, to the hest of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the systern, or those persons directly responsible for
gathering the inforrnatlan,
will abide by all conditions of the NCGO10000 General Permit and the approved Erosion aid Sediment Control
Plan -
If the approved Erosion and Sediment Control Pled is not compliant with Part II (Stormwater Pollutiork
Prevrtition I of the NCC 0100 0 G eneral Permit I will nonetheless ensure that all conditions of Part H of th-e
permit are met on the project at all times,
W I her-eby request novarage under thee- NCG010-000 Geq_ r Permit and understand that coverage under thi1
permit will constitute the permit requirements for the discharges) aril is enforc-eable in the same manner as an
individual permit_
Name of Project (musr match Ala): Carriage Farm Subdivision
Spedfl-c Lot Nurnbers (mustmatch AIb),
Legally Responsible Organizational Entity (must match 81); carriage Farm Development LL
1.
Lega I ly Res po r si b I e Re rso n (m rest mate, J32 & 63) : D avid M. Cyrus
Title of LegaIly Responsible Person (must match 133h); Member Manager
Na m e& Tit I e of S i it e d if Muth o used I nd ivid Lra
Differs from EegaIIV Responsible Persia:
Phone NomHer_ 919,669.5933
Signa6de of Lega11y Respi
Person or Authorized Individual
Date
* IMPORTANT NOTE. This form must be -signed by a respaas;bla rorporure -o fcer that owns or operates the construct;on activity,
.5u-ch as o presi'dent, secretary, treasurer, or vice present, or o rrronager that is outhorized fir occordance w;th Part jV, section 8,
Item (6) of the NCG0I0000 p4ermi �.