NCC243506_NOI Signed Certification_20241113

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO1.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)
at:Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury Street, 6.^Floor(Office
640K)1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR
122.22)
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 toexceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
lC I am the person responsible for the construction activities of this project,for satisfying the requirements of
thispermit, and for any civil or criminal penalties incurred due to violations of this permit.
l 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 forgathering the information.
aI will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment
ControlPian.
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 ll of
thepermit are met on the project at all times.
I 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
anindividual permit.
Name of Project must match Ala):Governors Club-Lot 891 Nash
Specific Lot Numbers(must match Alb): 891
Legally Responsible Organizational Entity(must match 81): GA 240 LLC
Legally Responsible Person (must match B2& B3): Josif Skela
Title of Legally Responsible Person (must match B3b1: Managing Member
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919.537 49
r .
/// I1- fLY
Sigt aturof Legally esponsible Person or Authorized Individual Date
*IMPORTANT TE:This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a pr sident,secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section
B,Item(6)of the NCG010000 permit.
Scanned with
m CamScanner