NCC192002_NOI Signed Certification_20191001

Print this form, complete, scan and upload tothe electronic WOL
Then, mail the original form to the INC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources 5turmwaterProgram
512N.Salisbury Street, 6mFloor (Office G4OK)
1612Mail Service Center
Raleigh, INC 27698'161Z
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute243-22�6B (i), any person who knowingly makes any false statement,
orcertification /nany application, record, report, plan, urother ducumeotfi&d or required tobemaintained
under this Article mrurule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$20,0O[V.
Under pcna|h/o[law, | certify that (chock all boxes toindirrteyouraAreanen1):
_/
mu | am the person /espmnsib|e for the construction activities ufthis project, forsatisfying the
requirernents of tWs permit, and for any civd or criminal penalties incurred clue. to vVations of this
pe/miL
y/
[� The information submitted in this M01 is, to the best ofmy know|edOe and he|ief, true, accumie' and
complete based on myinquiry ofthe person or persons whonnanag(-� the system, or those persons
directly responsible for gathering the information.
y/
�� | will abide hyall conditions ofthe NC.G0.10000 General Permit and the approved Erosion and
Scdiment[vnt/a|Plan.
If the approved Erosion and Sediment Control Plan is not cornpliant with Part 11 (Storn1water Pollution
Prevention Plan) of the NCGO10000 General Permit, | w|U nonetheless ensure that all conditions of
Part U of the permit are met on the project at all times.
"V | hereby requestcovumgeundorthe NCGO10000 General Permit and Understand that coverage Under
this Permit will constitute the permit requirements for the d5dargm(s) and is enforceable in the
oamemanner asanindividual permit.
Name of Proiect: Academy Pointe Phases 3 & 4
Legally Responsible Organizational Entity: Sam's Branch 11, LLC
Legally
Reid Smith
Title cfbana|lvReononsih|e Person: Ycooncr
*5isnature:
*Print Nam6and Title ofSigned ifAuthorized Individual
Differs from Permittee:
Phone Number:
IMPORTANT NOTE: Thisformmust besigned byoresponsible corporate officer that owns moperates the
construction activity, such osopresident, secretary, treasurer, mrvice president, u/omanager that b
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirementssee Part IV, Section B, Item kBof the NCG0,0000permit.