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HomeMy WebLinkAboutNCC192016_NOI Signed Certification_20190925Print 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, 61h Floor 1612 Mail Service Center Raleigh, NC 27699-1612 Per NC General Statute 143-215.6E (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 a fine not to exceed ten thousand dollars ($10,000). Under penalty of law, I certify that (check all boxes to indicate your agreement): FX1 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 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. ® I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. IN If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the permit are met on the project at all times. LI 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: Fort Bragg Federal Credit Union Legally Responsible Organizational Entity: )._ tC:�., (� 'c. .� F- C) C-R * Legally Responsible Person: - z--c-tlr d r , Title of Legally Responsible Person: C,,O iC1= V-tP AC.tA,a-. FF-tc:EKzz. Signature: Date: el 9- ( r,, * 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. City of Fayetteville 433 Hay Street Fayetteville, NC 28302 ToWhom it May Concern: This letter serves as authorization for Jennifer King of DB Incorporated and/or Richard Lodhck of RSL Commercial Architecture, on behalf of Ft. Bragg Federal Credit Union, to act as our representative/agent in all building and planning requirements including but not limited to soil erosion, storrnwater, etc. as it relates to our properties located at (New Branch) 1686 3kibo Road (Parce|#D418-2]-0349)and (Branch Renovation) 1838SkiboRoad, Fayetteville, N[ 28303 Si Carrie Rice Chief Financial Officer STATE OF CuV,�[OUNTY BEFORE ME, the undersigned authority, on this day per-sona|lyappeared known mme to be the person who signed the above letter. Given under myhand and seal ofoffice On this —G date of f&. 2019 Notary bric) 91&9042232 FOR reuxooLncxTmws- rAYSTrsv/LLs LocArows: *.lff'o(ft�ce. I jefiner Plaza, South rxoriv * 1638 Skibo Road, Fayetteville, mCz838 Bastogne Drive *a/oouummystreeLFayetteville, wcz8o|/ *m4onuutbrdRoad, Fayetteville, wCzo3o* MAILING 1.800,7912328 p413,omnofo wwmlbnhnaggfcv^og � rvtluracuwczmur