HomeMy WebLinkAboutNCC204551_NOI Signed Certification_20201009NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print illls fol'rn, complete, scan and upload to the elctront 11M
Ther; mad the original form to the IBC. DEMLR Stormwater Nagmni Ovk h $100 clheci: ifpa;ling by check) at:
Division of Energy, Wnerai & Land Resources Stonvwatei' Program
512 I',<, Salisbury Street, 6" Floor PKice Gu,M)
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 143-215.65B (i), ony person who knowingly n7akes any foiSE statement, rel)reSentotioll,
or certification in ony uppl'icotiol:, record, report" 171017, O1' Other docun7Pli'� fij'ed o!" r equlred to be maintaftied
render this article or a rule hmplemenfing this /-article ... shaP be guhtyy of a' Class 2 n7isderneonor ,.vhich n7ay
include a fine not to erceed ieo fhousund dollars ($10;000).
Under penalty of lavv, ! Ce'; flip; t' at Rheck all b'oxeS'to i' dilate your agreel1her:'-�•
u i aryl fir psi"SG11 1'cSl�QliSiiiie 1'Ji' the CQ115tI"uCtiDll aCtil!itIES Di i1115 i�rdjcC, idi' s�ti5€j iiig'il1e
reqlir mem or this penal, and for any civil or criminal penalries ?ncur red due to V3yladons D1"As
LeM1it-
1-he i"s1'Crmation submitted in this NC)l I5, to We beq of ivy 1C11CMedge ar d belleT; True, accurate, and
compike lamed cn my inquiry of the person or persons v'fho Itsanage tilt Systl r'l, 0;- lI:GSC pErsQlss
directly responsible for gathering the information.
f 11+ W ?i:iiDe by ali condiiiolls of the NC6010000 General Permit and the ap{ Fovea Erosion and
Sediment Control Plan.
L If tiw apiwoved Eralon and Scuimou Coi d0l An is not CQiT11.3llallt With, Psi t II SSiol'iii+udicr Poftliioll
Prevention Plan) of the NC6010000 General -Permit, I will nonetheless ensure that all conditions of
Part lI of Me permit are met on the project at all fillies.
I h reby request coverage under the NCG010000 General Permit and understand that coverage under
ON i::eri1`i'r; will cunSiitui2 rile perllllt requirements TDr the discharq e(s) and Is Enforceable in the
s rT?c riiallnci a S all li-AiViCiLlal permit.
I�ranhe-of Project:- 1 T e an S
Legally Responsible Chyanizational Entity!:
-Legally f0spansiblePEr50r1:- }C`l Wf�.-----'--------_---- -
Title of LcgAQ Respansihle Penn, d±
*Slgnature__�ti_
*PMA Name aild We o':' Apeo ii ,iiuMor!iK
PhoneNunhl?e'r:
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Gil(r�tL+�ri r)r rfr { I;r+'iWK, MA r-w !I ! JLr SO it Am OV qf Me Wli0.4600 J16004,