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HomeMy WebLinkAboutNCC191255_NOI Signed Certification_20190808NCGO1 Notice of Intent (NOI) Certification Form 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 Re»ourcesStornnvvater Program 512N.Salisbury Street, 6mFloor 1612Mail Service Center Raleigh, NC 27699-1612 Per NC General Statute243-225.6B (i),cny person who knowingly mmkescnyfalse statement, representation, or certification in any application, record, report, plan, orother documenttledmrequired tobemaintained under this Article urorule implementing this Article ... shall beguilty ufoClass 2misdemeanor which may include ofine not toexceed ten thousand dollars ($10,000). Under penalty oflaw, Icertify that (check all boxes toindicate your agreement): 93 1 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. III-" 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. b�~ |vviUabide byall conditions ofthe NCG010000 General Permit and the approved Erosion and d Control Plan. ,,,--"-Sediment Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions of Part Uofthe permit are met onthe project atall times. 8- | 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 asanindividual permit. Name ofProject: &44M&J AIA / 71A / C, - /X /C b�|���n�b�O�n���|E�� (� �� � * Legally Responsible Person: Title of Legally Responsible Person: Signature: *IMPORTANT 0OTE.-Dhisformmust be signed byoresponsible corporate officer that owns or operates the construction activity, such osopresident, secretory, treasurer, orvice president, oromanager that is authorized /naccordance with Part IV, Section 8,Item (6)ufthe yJCG0108D0permit. For more information on signatory requirements, see Part IV, Section B, Item @1ofthe N[G0D000permit.