NCC191858_NOI Signed Certification_20190917

Print this form, complete, scan and upload to the electronic NOL
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, 6 1h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (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 ofine not to exceed ten thousand dollars ($10000),
Under penalty of iavq, a certify that (check aH boxes to andicate your agreernent):
SJ / I am the persoin responsUe for the construction actk/itiles of this project, for satisfying the
requirements of this perrnit, and for any civil or criminal penaIties incurred due to violations of this
permt.
tl-2� - i"he information submitted in this NOl is, to the best of my knoMedge and belief, true, accurate, and
cornplete based on my, inquiry Of the person or persons who rnanage the system, or those persons
directly responsible forgathering the information.
Nl' i wffl abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and, SedirnQnt ControB Nan is not compliant with Part 11 (Starrnwater PdiUticn
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure, that aH conditions of
Part ii of the perry t are met on the project at aH timers.
i hereby request coverage under the NCGO10000 General (Permit and understand that coverage under
this pen -nit will COnStitUte the permit requirements for the discharge(s) and is enforce@Ue in the
sarne manner as an individual permit.
Name of Project: Woodfin
Legally Responsible Organizational Entity:
Legally Responsible
Title of Legally Resr
Signature:
Cloudbreak Investments, LLC
: By: Nathan Evans, Manager of Cloudbreak Investments, LLC
n: Manager
*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 Part IV, Section B, Item (6) of the NCGO10000 permit.