NCC202233_NOI Signed Certification_20200529

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, Complete, scan and upload to the elrrtronic NOt_
Then, mail the anginal firm to the NC ❑FMLR Stormwater Prnpram Iwith SIDD rheck if paying by rheckj at:
❑rVI90r, of Energy, Mineral & Lard Resource Stormwater program
512 N. Salisbury Street, V1 Flnnr (Office WK)
161 ] Mail Service Centwr
Raleigh, NC 27699-1617
D❑ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per lVC General Statute I43-215,66 (i), any person who knowingly makry any folse stoternrnt, represenrarlan,
or certrjScation In any opprrcarion, record, report plan, or other document filed or required to be maintairwd
under this Article or a rule impferric ntrng this A►"n'cle .. _ shall be guilty of a Class 2 rnkrkirneanor which may
include o fine not to exceed ten thousand doftorrs (510. b).
Under penalty of law, I cPrttfy that f check all hnxes to indicate your ilirPementl:
1 am the person responsible for the construction activities of this lw,iett, tot satisfying the
requirements of this permit, and for arty civil or criminal penalties incurred due to vkAations of this
permtt-
I he information submitted in this NO is, to the hest of my knowledge and belief, true, ar.rur0te, and
cvmplete baser€ on my inquiry of the person or persons who manage the system, or those persons
dirut tly responsible for gathering the information,
I will abkie by all conditions of the aQG010000 General Pe-rrni, and the apprft"l Frosion and
Sediment (;untrol Plan_
If the approved Erosion and Sediment Control Plan h nut compliant with Part II IStormwater Pollution
Prevention Plain I of the-CG010000 ctnrral Pcrmrt_ I will nonetl�rk).s insure that all rnndi[iuns ul
Part I� of the permit are met or the project at all times_
I hereby reqursr c:nverape under the NCGO1Clt7 O GcneraI Permit and understand that coverage under
this permit will constitute the permit requirements for the dnrharpe(sI and is enforLeablr in the
same manner as an individual permrr
Name of Pro)ect- ()Id Denning Farm Sandivision (Aoa& & Infrastructure Oat y
Legally Responsible Or antirational Entity- 5 B Building, Inc.
LepIly Responsible Person. Scottie RriswelI
Title of Legally Responsible Perwin: President
'Print Name and Tn* of Signed TAuthoruobd
Individual Differs from Permittee:
Phone Number- 919-427-260
. IMPORTANT MOTE: This form must he storied by a responsible carparatr affair that owns or operates the
ranstrtictibn activity, such as a prfuderit, secrrtory, treasurer, or rite president or a manager that is
authorded in accordanre with Part IV, Section ri, Item (r) of the NCGOI0" permrr.
For more informor1kri on sign arory requiremenM see Part IV, Section B, item (6) of thr NC6010000 peemit-