NCC202514_NOI Signed Certification_20200616

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Sto.rmwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Storrnwate.r Program
512 N. Salishury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27599-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC Genera! Statute 143-215.613 (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, l certify that (check all boxes to indicate your agveernent):
M/ I am the person responsibie 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 systern, orthose 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.
N if the approved Erosion and Sediment Control Plan isnot compliant with Part 11 (Stormwater 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,
N/ 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: jejf, Jjoij OF Ita..-ris Place, Jrra-ion fr' u-oCOfs 8-II,1'17� 1'rr� �8(p
Legally Responsible Organizational Entity: H i` lARS S T 208 tr220
Legally Responsible Person: 'bflolrl Title of of Legally Responsible Person:
*Signature: tok� Date:
"`Print Name and Title of Signed if Authorized
Individual Differs from Permittee;
Phone Number: 1/ 0-y66-90104
llvtPORTANT NOTE. This form Must be signed by a responsible corporate officer that owns or operotes the
construction activity, Stich as a president, secretary, treasurer, or vice president, or a manager that is
authorized irr accordance with Part W, Section B, Item (6) of the NCG010000 permit.
ror more informntio. n on signatory requirements, see Part II/, Section B, item (6) of the NCG010000 permit.