NCC201068_NOI Signed Certification with FRO_20200320

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print 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, 6tn Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (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 o 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
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 NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
• If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 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 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: Corvain Athletic Field
Legally Responsible Organizational Entity: CCSSH, LLC
Legally Responsible Person: Stacey Haskell
Title of Legally Responsib Person: ExegLoe Director
*Signature:X Date: 3 u go
*Print Name an"of igned if Authorized
Individual Differs from Permittee:
Phone Number: 704-717-7550
* 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 Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. If the financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Corvian Charter School
2. Address of land —disturbing activity: 4041 Johnston Oehler Road Charlotte, North Carolina 28269
3. Approximate date land -disturbing activity will commence: February 3
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Athletic Fields
5. Approximate acreage of land to be disturbed or uncovered: 11.00
6. List total site acreage: 36.77
7. Landowners of Record (Use blank page to list additional owners):
Name: CCSSH, LLC
Address: 9501 David Taylor Dr, Charlotte, North Carolina 28262
Telephone: [phone]
(Area Code)
Email A
Signatur
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 32260 page 414 Book 34076 Page 185
Book 33569 Page 34
Book Page
2020
Year
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: CCSSH, LLC
Address: 9501 David Taylor Dr, Charlotte, North Carolina 28262
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(Area Code)
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
t ,� lIf 0 _e c I oS c j« 0 q 41 V.1
Printed Name ,,' Title
I,
/Z/'�/I
Date
_ a Notary Public of the County
of State of hereby
certify that personally
L
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this day
o 7 3 •/��
f G ��C_f�.fYi. �'l L'-i O I 1
Notary Signature:
My Commission expires:
GEORGIANA LASALLE
Notary Public - North Carolina
VUR
Mecklenburg County
My Commission Expires Mar 15, 2010
CHARLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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