NCC190513_NOI Signed Certification_20190605

1YCG01 Notice of Intent (1401) Certification Fm���lrn
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NCGeneralStatute143-225.6B(i), any person who knowingly makes onyfalse statement,
or certification/n any application, record, report, plan, nr other docunnentfiledor required tnbemaintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include o//ne not to exceed ten thousand dollars /$1O,0O(V.
Under penalty of law, | certify that(check all boxes to indicate your agreement):
DQ I am the person responsible for the construction activities of this project,for satisfying the
requirements ofthis permit, and for any civil or criminal penalties incurred due to violations nfthis
permit.
03 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.
* | will abide by all conditions ofthe and the approved Erosion and
Sediment Control Plan.
DQ If the approved Erosion and Sediment Control Plan is not compliant with Part || (Stmrmwater Pollution
Prevention Plan) of the | will nonetheless ensure that all conditions of
Part || of the permit are met onthe project a1 all times.
QD | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner auan individual permit.
Name of Project: Glen Oaks Subdivision
Legally Responsible Organizational Entity: Glen Oaks South' LL[
* Legally Responsible Peo K4r
on� . 8rianMassengiU
Title of Legally Responsible P « hd Person
Signature: "*.= _
� IMPORTANT NOTE: Thbform must be signed byo responsiblemrporate officer that owns oroperates the
construction activity,such oso president,secretary, treasurer, Vr vice president, oro manager that b
authorized in accordance with Port IV,Section B, Item (6)of the NCGO10000permit.
For more in/bnnobon on signatory requirements,see Part IV, Section 8, Item (6)of the NCG020000penn/t.