NCC190535_NOI Signed Certification (2)_20190606

NCGO1 Notice of Intent (NOI) Certification or
Di rections:
Print this forrn,complete,scan and upload to the electronic NUI.
1hen,rnail 1,he original form to the NC DEMLR Stormwater Progiam at
Divi5jon of Energy, Mineral&Land Resources Stormwater,Program
S 12 N.Salisbury Street, 6"1 Floor
1612 Mail Service Center
R a le igh, PVC 2 7 6 9 9­16 1.2
Per NC.'GereraiStarate 143 215.6B(l), any porsort who knowingly makes arlY,jolse statement, repr,esentotion,
or certification In any opplication, record, report,playa,or other document filed or required ro be maintained
uoder this Article or a rule irrtpleorc�nting this ArCicle. . .shall be guilty of a Class 2 misdemeanor which may
include a fine not to(-.,xceed ten thousand dollars($10,000).
lJnder Penalty of law, I certify that(check all boxes to incf cat(,,n your
I n,n the pet,.,,on for thr,comtruction actwit;e�of this project, for-satisfyinE,the
re quir('­rnerlt!:�of this petMit, and for d1ly civil Of Criminal pcni-31hes mcurre,d due to violations of this
permit.
The information 5W)Mitted in this NOI is, to the twst of my knowledge and belief,true,accurate,and
complete based orF my inquiry of the person or persons who rrianage the systern,or-those persons
directly responsible for gathering th,sr fojrnanoi
Ik I will abide by all conditions of the P!I,Itf.,ir drid the jplatoved Erasion anci
S(,adimont Control Plan.
11 the aptiroved Frc�,lton and i(,dirnpnt ni'd rN Plan i,,,not compliant with Part 11 (,f torrnwAter.pofje,jtjcan
Prevention Plan)of the v. I t, I Will nonetheless cn,,�ure that all conditions of
Part t II of the per rnit are met on the projoct a t isd IErrwn',
Ihaesre b V r(2,q u e i t co v e 1,)P�,e, U rl d f.s r t"I (,",I 1 rr i I o f �'i a r d u n d e.r s ta n d t h a t cover a ge under
this Permit will constitute the pe(rmt reejUiWtTWW's for the and is enforceahk, in the
same marner as an fridividual pertnit.
Narne of Project, The Res ex�ves, at lea sh(,-.xs Cree k
Legally Responsible Organizational Entity: .jiall Group
Legally Responsible Person:
Title of Legally Responsible Person-
Signature: Da t e
IMPO RTA N T NOTE. This jr)rm must be.sinned by a res p o o s ib le corporate officer that awns or operates the
constructiort activity, such us a President, secretary, treasurer, or vice President,or a manager that is
authorized in accordance with Part IV, Section 6, Item(6)of the NC(301 0000 permit.
For more information art signatory requirernentS,see Part IV,Section 8, Item(6)of the N(GO10000 permit.