NCC202033_NOI Signed Certification_20200520

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail' the original form to the NC DEMLR 5tormwater 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
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per lVC Generai5totute 143-215.68 (i), any person who knowingly makes any+ false stotement, representation,
or certification in any application, record, report, plan, or other document filed or required to be mointoined
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):
X1 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
X
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
# will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
_ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (5tormwater Pallutian
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that ail conditions of
Part 11 of the permit are met on the project at all times.
XI hereby request coverage under the NCG010000 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: Arlie Meadows
Legally Responsible Organizational Entity: KDP Development, LLC
Legally Responsible Person: Phil Stephenson
Title of Legally Responsible Person: Member Manager
*Signatur :
*Print Name and Title of Signed
individual Differs from Permittee:
Phone Number: 91 g-427-8654
Date: _15 F //,
*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 FartIV, Section 8, item (6) of the NCG010000 permit.
Far more information on signatory requirements, see Part IV, Section 8, Item (6) of the IVCGO10000 permit.