NCC191296_NOI Signed Certification_20190812

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (iJ, 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 enalty of law, I certify that (check all boxes to indicate your agreement):
I 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.
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.
d/ 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
/ Part II of the permit are met on the project at all times.
�I( 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 an individual permit.
Name of Project:
Legally Responsible Organiz
* Legally Responsible Person:
Title of Legally Responsible Person:��-21 -
Signature:
ate: `6 - % �
* 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 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
C

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. IIll
1. Project Name d i I Sr�A ru 4 rCl4--Pc
2. Location of land -disturbing activity: Jurisdiction )6(16Z G3,� Icli(¢,�L(Wake Co. or Municipality)
Highway/Street , t1\CT7AQZ_q, oveLatitude , -S, V]����7a Longitude �, -7 3Q
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): . iO
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name�,G` , b�JE-mail Address e "A5Z rels,�A �/vl
Telephone' �'f c��,a— 077S Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Wards �r��s-IYUc�;I�., �� �� LAC qHI �IWa () S `� I �1-L10(oa- %oC7
Name(s) �` Telephone Fax or E-mail address
Ian t)c� rr l ANee S+e / D� I12fL
Current Mailing Mdress Current Stree Address
C/w/Jc. �5( 3
City J State Zip City State Zip
8. Deed Book No. % 7; �// Page No P;�39_5Provide a copy of the most current deed.
Part B.
1. Person(s) or firms) who are financially responsible for the land -disturbing activity (Provide
� "c-omprehensive list of all responsible parties on an attached sheet. Include requested information):
V UG��SO CD ✓lS� Ylt r ��. , n FU (` �`��-P .t 'lam .��0 n ,-.co
Name
Current Mailing Add
City
0
State Zip
Telephone���'�LrG,a — O%`7�
E-mail Address
Current Street
dress
City State Zip
Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
The above information is true and correct to the best of my Knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
l ype or print name
Signature
Title or Authority
Date
I , V I C k i e 5- I<� �� , a Notary Public of the County of W GLk�
State of North Carolina, hereby certify that c!rl jct;,�i n l� . �a r d appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 2S day of
�ecn e . 20 I g
Notary
My commission expires � / Z3 � �I