NCC191752_NOI Signed Certification_20190918

NCG01 Notice of Intent (N01) Certification Form
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 ofEnergy, Mineral & Land Resources StonmwaterProgram
5l2N.Salisbury Street, 6thF|onr
1612Mail Service Center
Raleigh, NC 27699-1612
Per N[General Statute 143-215.68(i),any person who knowingly makes onyfalsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include offnenot toexceed ten thousand dollars /$1Ll00O/.
Under perialty of law, I certify that (check all boxes to indicate your agreement):
|amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
X 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.
Y | will abide byall conditions ofthe and the approved Erosion and
Sediment Control Plan.
N If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe Iwill nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
0Q | hereby request coverage under the 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.
Legally Responsible Organizational Entity: Caviness Land Development, Inc.
* Legally Responsible Person: Watson Caviness
Title ofLegally Responsible n:
Signature:
Date: 09/06/2019
IMPORTANT NOTE: Thisform must be signed byoresponsible corporate officer that owns moperates 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 onsignatory requirements, see Part IV, Section B, Item(6) of the0CG00000 permit.