NCC231326_NOI Signed Certification_20230505

NCGO1 Notice of Intent (N0I) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI. bycheck
Program (with$100 check if paying )at:
Then,mail the original vision of Energy, Mirm to the Nc ne al&Land ResourcesLR Stormwater c Stormwater Program
512 N.Salisbury Street,60,Floor(Office 640K)
1612 Mail Service Center
Raleigh,NC 27699-1612
LETE.
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YTION HAS BEEN ACCEPTED AS SIGNATURE(NOT DIGITAL) 4QOCFRP122.22J
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL
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($10,000).
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.
El 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 person or persons who manage the system,or those persons directly responsible for
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
Q I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
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): Lakes at Riverbend— Phase 1 - Lots 263-266
Specific Lot Numbers(must match Alb): 263,264,265,266
Permittee(must match 81): NVR Inc.
Legally Responsible Person(must match 82&83): Chris Reisch
Title of Legally Responsible Person(must match 83b): VP
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person: Jon Vecchiarelti - Project Manager
Phone Number: 757-771-5055
Signature of Legally Responsible Person or Authorized Individual 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 president,or a manager that is authorized in accordance with Part IV,Section 8,
Item(6)of the NCG010000 permit.