NCC204751_NOI Signed Certification_20201021

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
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, & Floor (Office 640K)
1612 Mall 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 General5tatute 143-215.68 (1), any person who knowingly makes any false statement, representation,
or certrflcation In any application, record, report, plan, or other documentfUed or required to be malntafned
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 ($20,000).
Linder penalty of law, I certify that (check all boxes to Indicate your agreement):
13 1 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.
IN The information submitted In this N01 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.
13 1 will abide by all conditions of the 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 it (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.
0 1 hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permlt will constitute the permit requirements for the discharge(s) and Is enforceable In the
same manner as an Individual permit.
Name of Project: Churchill Commons Lot 4 Slto
Legally Responsible 0 ganhational Entity: LDS II, LLC
Legally Responsible Person: Jaynes Marshall
Title of Legally Responsible Person: Manager
*Signature, �Date: 1011512020
ad�lvlduomf
Title of Slgne IfAuth Ized
from Perm ttee:
Phone Number: 336.282-1590
*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 B, item (6) of the NCG020000 permit
For more Information on signatory requirements, see Part IV, Section B, Item f6) of the N00010000 permit.