NCC192024_NOI Signed Certification_20190925

IV C C3' 01 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 Storn')water Program at:
Division of Energy,Mineral & Land Resources StomnwoterProgram
S12N.Salisbury Street, 6mFloor
1612Mail Service Center
Raleigh, NC%7699-1613
Per NC General Statute 143-21£68(i)any person who knowingly makes anyfalse statement, representation,
orcertification /nany application, record, report, plan, or other documentfiled 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 ofinenot toexceed ten thousand dollars /$2(\0UO/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
iamthe 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.
IR 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.
00 / will abide byall conditions nfthe NCGO10000 General Permi.11 and the approved Erouionand
Sediment Control Plan.
X If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) mfthe NICG010000 General Permit, > will nonetheless ensure that all conditions of
Part Uofthe permit are met nnthe project atall times.
X ) 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.
Name of Project: Cypress Lakes Village Section 10 - Lots 279, 280 & 321
Legally Responsible Organizational Entity: CaViDeSG Land Development, Inc.
* Legally Responsible Person: Watson CGVine8G
Title ofLegally Responsible Owner/Ma�ager
Date: 09/23/2019
*
IMPORTANT NOTE. Thisform must be signed byoresponsible 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 onsignatory requirements, see Part IV, Section £LItem A8qfthe N[G010DD0permit.