NCC204553_NOI Signed Certification_20201013

NCG01 Notice of lntent (NOl) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOl.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if poying by checkl at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 5a0K)
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 Generol Stotute 143-21"5.68 (i), ony person who knowingly mokes any false stotement, representation,
or certificotion in any applicotion, record, report, plon, or other document filed or required to be mointoined
under this Article or a rule implementing this Article . . . sholl be guilty of o Closs 2 misdemeonor which moy
include a fine not to exceed ten thousond dollars (5L0,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
A I 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.
Z The information submitted in this NOI is, io 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.
d I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan,
Z lf the approved Erosion and Sediment ControlPlan is not compliant with Part ll (Stormwater Pollution
Prevention Plan) of the NC-Q01,--0_Q00 General Perrnit, lwill nonetheless ensure that allconditions of
Part ll of the permit are met on the project at all times.
d I hereby request coverage under the NCG010000 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: Pennybyrn at Maryfield
LegallyResponsible Organizational Entity: Maryfield, lnc.
Legally Respons ible Person:Richard Newman
k</' A,,''
*Print Name and Title of Signed if Authorized
lndividual Permittee:- J ,Atvc-c2..*r --t ,Z-ss.-o(-*t
Phone Number: 3S1t hLl '7ltto
* IMPORTANT NOTE: This form must be signed by o responsible corporate officer that owns or operates the
construction activity, such os a president, secrelory, treosurer, orvice president, or o monoger that is
outhorized in occordonce with Port lV, Section B, ltem (6) of the NCG010000 permit.
For more information on signotory requirements, see Pqrt lV, Section B, ltem (6) of the NCG01"0000 permit.