NCC192124_NOI Signed Certification_20191002

NCGO1 Notice of Intent (N01) Certification Form
Directions:
4,11 11 iii , .. arr iii � TT I-Wgrar-P
512 N. Salisbury Street, 6" Floor (Office 640K)
1,612 Mail Service Center
i)o rqo,r 1V1AlHl.'TFfIS FOR RA OR YOUR Al,"PLCAT Ill ON HAS BEEN
REVIEWED AND COMP11JE111
777F)l 77,11 -
or certification in any application, record, report', plan, or other documentfiled or required to be maintained
under this Article or a rule implementing this Article. . , sh,oll be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousanddollars ($10,000)4
Under penalty of law, 1: certify that (check ak boxes to indicate your agreement):
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, NOII 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.
Fy--K" i will abide by all conditions of the 1 CG01.0000 Generzfl Pen ru and the approved Erosion and
Sediment Control Plan,
ri�"" If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCCiQ10000 GeneraI Flee-mit, I will nonetheless enSUre that all conditions of
Dart H of the permit are met on the project at all times,
lr I hereby request coverage under the INCGO110000 Generifl PleP rnit 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,
1­ �
Name of Project: J ) L'-'_r116 c:k_r 4-D c)
insible Organizational Entity:
Legally Responsible Person:
Title of Legally Responsible Person: NJJ'r P CAP e-
: *Signature: Date—14 ­3�s)_3___ _.
*Print Name and Title of signed if Authorized Cl)
Individual Differs from Permittee: _k4c
Phone Plumber -
3.S.1 W-5 - - - —
IMPORTANT NOTE., This form m ust be signed by a responsible corporate officer th at owns or operates th e
construction activity, such a5 a president, secretary, treasurer, or vice president, or a mianager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCG010000 permit.
Ill lillill illifliF IF III! IlM, a. gill lllli� ll