NCC190523_NOI Signed Certification_20190606

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NCG41 Notice of Intent (NOI) Certification Form
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Directions:
Print this form, complete, scan and upload to the electronic NO].
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" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143 215.6B (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).
Under malty of law, I certify that (check all boxes to indicate your agreement):
l 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.
I�The information submitted in this N01 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.
V/ I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
ediment Control Plan.
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If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
revention Plan) of the NCGO10000 General Permi#, l will nonetheless ensure that all conditions of
/,Phereby
art II of the permit are met on the project at all times.
request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements forthe discharge(s) and is enforceable in the
same manner as an individual permit.
Legally Responsible Organizational Entity:
* Legally R ns Person:
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Date: `eO
* IMPORTANT NOTE: This form must be signed by a responsible 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, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.

F. PROPOSED PERMITTEE CERTIFICATION
l,_ dZ,L -5, „1 CLr1el/' , hereby notify the DEMt_R that I have acquired through sale, lease,
development agreement, or other legal transfer, the project/property covered by the stormwater management
permit and/or the responsibility for constructing and/or operating and maintaining the permitted stormwater
management system. 1 acknowledge and attest that I have received a copy of: (select all that apply):
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he most recent permit;
he designer's certification for each SCM;
[[yy� ny recorded deed restrictions, covenants, common areas, drainage easements or plats
e approved plans and/or approved as -built plans;
he approved operation and maintenance agreement;
2 ast maintenance records from the previous permittee (where required);
a copy of the most recent inspection report;
Check here if the proposed permittee agrees to be the entity responsible for addressing any compliance
issues outlined in the Compliance Inspection Report. If checked, the proposed permittee must provide a
written document statement, with a "plan of action and schedule" addressed to this office stating that they will
bring the project into compliance upon receipt of the transferred permit. This written plan of action and
schedule" must be received by the Division before the Division will transfer the permit.
I have reviewed the permit, approved plans and other documents listed above, and i acknowledge that I will
comply with the terms and conditions of the permit. I will construct the project's built -upon area as shown on the
approve�F'plans, nd I will (construct), operate and maintain the approved stormwater management system
pursuant to the r quirements ted Jinhe permit and in the operation and maintenance agreement.
Sig nat Date: d o/9
County of
a Notary Public for the State of
do hereby certify that
personally appeared before me this the day of 20 and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature
My commission expires
Stormwater Permit Transfer Application Form Page 6 of 7 April 27, 2018