NCC202901_NOI Signed Certification_20200715

NCGO1 Notice of Intent (N01) Certification Form
Print this form,complete,scan and upload to the electronic NOI.
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,6'Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MA�L THIS FORM OR PAYMENT UNTIL YOUR APPLICAT!"ON HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 243-215.6BAl any person who knowingly makes ony/bbestatement.
or certification in any application, record,report,plan, or other documentfled or required to be maintained
under this Article ororule implementing this Article' ''shall be guilty ofmClass 2 misdemeanor which may
include ofina not to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
0 | 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.
0 The information submitted in this NO[ 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.
0 | will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe , |will nonetheless ensure that all conditions of
Part||of the permit are met on the project at all times.
0 > hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s)and is enforceable in the
same manner asan individual permit.
-Nameof Project: BRANNON ROAD SUBDIVISION
-Legally Responsible Organizational
-Legally Responsible Person:
-Title of Legally
-*Signature: Date:
*Print Name and Title�f Signed if Authf"ized
Individual DiftersfromPermittee:
Ph b 919-266-0033
*IMPORTANTNOTE. This form must be signed byo responsible corporate officer that owns mroperates 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 NCGO10000permit.
For more information on signatory requirements,see Part IV,SectiomB, Item(6)nf the/VOSO1UOOOpermit.