NCC232337_NOI Signed Certification_20230804

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic N0.
Then, mail the oh0|no|form to the NC DEKALRStormvvater Program (with $100 check if paying bycheck) at:
Division of Energy, Mineral fk Land Resources StormvvoterProgram
512 N.Salisbury Street, 6*Floor(Office 64OK)
1612 Mail Service Center
Raleigh, NC27699'1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE|FORM
—^—^YOU MAIL MUST BE COMPLETED WITH
^N ORIGINAL SIGNATURE
'(NOT`DIGITAL)
'-' -` ^-R`122.22]
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification/n any application, record, report,plan, u/other dooun7antfiledorrequired to be maintained under this
Article o/o rule implementing this Article. . .shall be guilty ofo Class Jnnisdenneonurvvhichnnoy/ndudeofinenotto
exceed ten thousand dollars($1(I0O0).
Under penalty of law, | certify that(check all boxes to indicate your agreenmunt):
[�l 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.
[�l The information submitted in this NO| is,tothe best ufmy 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.
��
�� |will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan,
Fv4 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe NCGO10000 General Permit |will nonetheless ensure that all conditions of Part || ofthe
permit are met on the project at all times.
[�l | hereby request coverage under the NCGO10000 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): Bri htNo d F Phase 5A
Numbers-Specific Lot
-Permittee (must match B1): Forestar (USA) Real Estate Group, Inc.
ResponsibleJason Ri h rk
Legally-Title of \/P Real Estate Investment & Development
Print Name @ Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 919-309-5291
Signatu[4'of Legally Responsible Person or Authorized Individual Date
~ 0NPOR34NTNOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such oxopresident,sec/ to/)� treasurer,n/vice president, o/o manager that is authorized hn accordance with Part/K Section B,
Item(6)of the N[G02O000permit.