NCC242925_NOI Signed Certification_20241009

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NCGO1 Notice of Intent (N01) Certification Form I
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Directions: I
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120•check if paying by check)
at: ; ,.
Division of Energy, Mineral &Land Resources Stormwater Program A 1
512 N.Salisbury Street, 6th Floor(Office 640K) ' '`,
1612 Mail Service Center ! i
Raleigh, NC 27699-1612 1
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THtsF.ORM"Y InMi. gfi t tlaai'ETED.Ik,ifaAN'©RIGINAL 51GN;4tg E(NOT-blGgA:0 j4U CR`7.2 ,j... uaa -d..w:f.x-:.«..,a, ... _..... H..vc�.-��s8aws:x„v i�af:ua.,.1 a+c.yaJancr_.xaN» . =r:,H.
Per NC General Statute 143-215.6E(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). ',
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Under penalty of law, I certify that(check all boxes to indicate your agreement): `
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Q I am the person responsible for the construction activities of this project,for satisfying:the requirernerits of this '
permit,and for any civil or criminal penalties incurred due to violationsfof.this permit: , •`•r 11'
0✓ The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, antd complete
based on my inquiry ofthe person,or persons who manage the system, or,those persons,di rectly:resporisible,for
gathering the information. E, r • r1! (, tIIl1 i:' )s, ,p
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Cl. I will abide by all conditions of the NCG010000 General Permit and the approved Erosion.arid Sed,imenttControl: i
Plan., • , ., •t I:}A'' i 'A ` •A , 4f,;, I , : I
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0 If the approved Erosion and'Sediment Control Plan is not compliant with Part Ilf(Stor`mwater Pollution 1' I
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. " + t
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E✓ I hereby request coverage•under the.NCGO10000 General Permit and understar cl that coveragelCinder:this ;
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit. ti ,I . 'vt ,» ' l! i ! ' i li .I!: l i,! I = ., ,.
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Project (must ): Alleghany High'School Additions�s ' .r a ' i" i' 1 l` '»i#
Name, match Ala &'Ren""ovations � ' �1' ! ��,' ; �
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_` ' F , lt � t ,Specific Lot Numbers(must m tchAlb): - a� ' "' ,• , � !
• e .Alleghany CountyBoard " t1 iI (I ' j ";''' I ' A
P rmittee-{must matchB1): g, y of Education )1. , 10 ( 1
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Legally Responsible Person(must match B2&B3): Sid Carrier I' .. F,;' : ;, I,:. t i lit
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Title of Legally Responsible Person (must match.B3b): Director of Facilities. ii ,I , G I i `,� ?€ll;; Ll I A
Print Name&Title of Signed if Authorized ll 1 i ' ) I " `r°` 1
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Individual Differs from Legally Res onsible:Person: "
?.`.:..ipany�'3�. ,.�{•' 1��r � f `i.`'R{ � ,l&e'. i,.t! i.l , �i.
• Phone Number: 336-657-7805 L } i,IA i '' . `1 ! 1 `, "`ill I'
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Signature of Legally R sponsible Person or Authorized Individual ' ' 1 f.:Date, �,. j, i i
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IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or'operates•the,construction actwrty,,
such as a president,secretary; treasurer,or vice president, or a manager thatis authorized in dccordince with Part 1V Section B•
Item(6)of the NCG010000 permit. : ' ' ,,, ' :;t,' s
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