NCC203065_NOI Signed Certification_20200812

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 Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater 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 BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (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 a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
XI 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
complete based on my inquiry of the person or persons who manage the system, or those 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.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
/ Prevention Plan) of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
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. „n I
Name of Project: GV4-E Pnes Lo -f- 20 �Z)
Lf l j L-1 2-
Legally Responsible Organizational Entity: dYL'�sC� f+DmeS LLC-
Legally Responsible Person: N�� 7j'D kvA S0A—
Title of Legally R ps onsibl Person: Wli1QOxtr1Q
*Signature: Date (D-5.2x�)24D
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number:
* 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 Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and,
if the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
Project Name: Gretchen Pines Phase 1 - Lots 20 21, 41 & 42
2. Location of land -disturbing activity: County Moore City or Township Mineral Springs Township
Highway/Street Gretchen Road Latitude N 35.2084' Longitude W-79.1639°
3. Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.87 Acres
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Travina Love
Telephone [phone] Cell #
E-mail Address travinalove(donsitehomesnc.com
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
T.K.C.S.J.M. Harris, LLC
Name
4292 Dowd Road
Current Mailing Address
Carthage NC 28327
City State Zip
910-947-2112
Telephone
Same
Current Street Address
Fax Number
Same
City State Zip
10. Deed Book No. 5090 Page No. 463 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Onsite Homes. LLC
Name
2919 Breezewood Avenue, Suite 300
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
nediohnson(cDonsitehomesnc.com
E-mail Address
Same
Current Street Address
Same
City State Zip
Fax Number 910-483-5195

2. (a) If the Financially Responsible Party
Carolina is not:a resident of North Carolina, give name and street
address of the designated North
E-mail Address
Name
Current Mailing Address
Current Street Address
City
State Zip City State Zip
Telephone
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy f the
street address of the Registered Agent f Assumed ame. If the Financially Responsible
Party is a Corporation, give
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State
Fax Number
Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Natha Johnson �
Type or print name
Signature
tlrGlVLove
State of North Carolina, hereby certify that
personally before me this day and being
Managing Member
Title or Authority
Date
a Notary Public of the County of CWbLA-j&_r1d
appeared
duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day
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