NCC202078_NOI Signed Certification_20200519

Direptions:.
Print this form, complete, scan and upload to the electronic Nol.
Then, marl the original form to the NC DEMLR St.ormwater Program (with $100 cheek if paying by check) at: l
Division of Energy.. Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6' Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAID, THIS FORM OR PAY6 TENT UNTIL YOUR APPOCATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-.215.6E (i), any person who knowinglymakes. a0y 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):
I�/ 1 am the person responsible for the construction activitles 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 Erasion and
% Sediment Control Plan.
P if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Storm water Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
of I hereby request coverage under the NC(3010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
saute manner as an individual permit.
Name of Project: —T-ke cl s o.i- T su b�vr Cc�rc�� Roo�c........w.._47.cry... J jw-6.S+aTo+yrq.
Legally Responsible organizational Entity:
Legally Responsible Person: Chris .; Cr�r-'Ie r-
Title of Legally Responsible Person:
Date: S- I S- zo
*Print Name and Title of Signed if Authorized /
Individual Differs from Permittee: G�,e/5��/Te"--
Phone Number:,
* 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 fart IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Mari IV, Section B, Item (6) of the NCG010000 permit,