NCC200832_NOI Signed Certification_20200305

NCGO1 Notice of Intent (N0I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NQI.
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 5tormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D❑ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (ij, any person who knowingly makes any false statement representation,
or cert►fication in any application, record, report, plan, or other document filed or required to be main toined
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):
® 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
perm it.
IR The information submitted in this NDi 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.
—lx 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.
® I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements far the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: Town of Nags Head W. Side Multi -Use Path PH 8C
Legally Responsible ❑rganixationaI Entity: Town of Naas Head
Legally Responsible Person: Cliff Og burn
Title of Legally Responsible Person: Town Manager
*Signature:
*Print Name and Title of Signed iAuthorized
Individual Differs from Permittee:
Phone Number: 252.449.2010
Date: Feb.28
* 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 IVC60I0000 permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.