NCC233276_NOI Signed Certification_20231102

NOC301 Notice of Intent (NOI) Certification Form
Directions:
Print this form. complete. scan and upload to the electronic Na.
Then, mail the original form to the NCDEMLRgormwater Program (with$100 check if paying by check)at:
Division of Energy. Mineral & Land Fbsourcesgormwater Program
512 N. Salisbury greet, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC27699-1612
DO NOT M AI L THIS FORM OR PAW ENT UNIT L YOUR AMU CAI1 ON HAS 8®V
REVI BNB)AND ACCEPTED AS(OM PLETE
Per NC General 3atute 143-215.6B(i), any person who knowingly makes any false statement. representation,
or codification in any application. record, report.plan. or other document filed or required to be maintained
under this Artide or a rule implementing this Artide. . . shall be guilty of a Gass 2 misdemeanor which may
indude 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.
X 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.
X I will abide by all conditions of the N( J10000 General Frrnit and the approved Erosion and
Sediment Control Ran.
:X If the approved Erosion and Sediment Control Ran isnot compliant with Part II (gormwater Pollution
Prevention Ran)of the NCG010000 General F�rmit, I will nonethelc.M ensure that all conditions of
Part II of the permit are met on the project at all times
X I hereby request coverage under the N00010000 General Farmit and understand that coverage under
this permit will constitute the permit requirements for thedischarge(s)and is enforceable in the
same manner as an individual permit.
Name of Project: Brantley Place Phase 1 B & 1 C
Legally Responsible Organizational Entity: SDH Raleigh, LLC
Legally Responsible Person: G. Michael Kahm
Title of Legally Respo ble n: • e P • , Land Development
*Sgnature: /l Date: 11-1-23
*Print Name d of Sgn if horized
Individual 'ffers from Fermittee::
Phone Number: [phone]
* IMPORTANT NOTE This form must be signed by a req)onsible 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. action B. Item(6)of the NCG910000 permit.
For more information on signatory requirements .'e Part IV, S3ction B. Item(6)of the NCCX710000 permit.