NCC202926_NOI Signed Certification_20200717

N GO1 Notice of Intent (NOI) Ceri ification Form
Directions:
Print this form,complete,scan and upload to the electronic Not.
Then, mail the on inal form to the NC DEMLR Stormwater Program (vYith $100 the k if paying by check)at:
Division of Energy, Mineral & Land Resources Stomwater Program
512 N.Salisbury Street,6'Floor(OfFic 640K)
1612 Mail Service Center
Raleigh, NC 27699-1 12
DO NOT M I THIS FORM OR PAYMENT UNT11-YOL RAPPLICATION HAS BEEN
REVIEWED AND ACCEPTED S CC MPLETE
er iVC General Statut 143-215.6E(i), any person who knowingl makes any false statement,representation,
r certification in a l y pplication, record,report,plan, or other d cume�t filed or req fired to be maintained
nd r this Article or a i ule implementing this Article. . .shall be guilty o 11a Class 2 mi 'demeanor which may
nclb de a fine not toe eed ten thousand dollars($10,000).
nd r penalty of law, I certify that (check all boxes to indicate your agr ement):
I am the p rs n responsible for the construction activiti 2s of t! is project,fo satisfying the
requirements of this permit, and for any civil or criminal penal ies incurred ue to violations of this
permit.
The information submitted in this Not is,to the best of iny kn wledge and belief,true, accurate, and
complete bas d on my inquiry of the person or persons who -anage the sy tem, or those persons
directly re p nsible for gathering the information.
I will abide b all conditions of the NCGO10000 General Dermit and the approved Erosion and
Sediment on trot an.
If the approved Erosion and Sediment Control Plan is not comr liant with Pat II (Stormwater Pollution
Preventio r PI 3 n) of the NCGO10000 General Permit I wi II non ,theless ensu r a that all conditions of
Part II of the permit are met on the project at all times.
I hereby r qu st coverage under the NCGO10000 General Per it and under tand that coverage under
this permi w 1I constitute the permit requirements for the disgharge(s) and s enforceable in the
same man er as an individual permit. IIII
ame of Project: c1ger Village
eg Ily Responsible Or anizational Entity: R11 Com nv, LLC
egally Responsible Pe son: Douglas Johnson
itle of Legally Responsible Person: Member
Sigpature: Date: 3 Q
Print Name and Title of igned if Auth ized
lndfvidual Differs fro Permittee: Dock ;:�-v 1"',('�vS�—�
ho a Number: Lt Q-So
* IIWP I RTANT NOTE: Th's form must be signed by a responsible co poratJ officer that(owns or operates the
consruction activity,
si ich as a president,secretary, treasurer, or lice pr' sident, or a anager that is
uthorized in accordance with Part IV,Section B, Item (6)of the NCGO10 900 permit.
For more information c n signatory requirements, see Part IV, Section B, item (6)of the NCGO10000 permit.
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