NCC204847_NOI Signed Certification_20201028

Print this form, complete, scan and upload tothe electronic N0.
Then mail the original funn to the NC DEMLAStormowaterProgram (with $100 check /fpaying 6xcheck) at:
Division of Energy, Mineral & Land Resources 0nrmwaterProgram
512N.Salisbury Street, 6 thFloor (Office 64OK\
1612 Mail Service Center
Raleigh, NCZ76991613
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-215.6B/i�.any person who knowingly makes m9falsestatement.
representation,�
orcertification /nany application, record, �oypor�ka�orotheroocunrentfi/edorrequiredtobe
under this Article ororule implementing this Article ... shall beguilty mfOClass 2misdemeanor which may
�c�x��o/�o�
x�not�uexcee�tend�uusun�do/��($2[lOOD). -^
Under penalty pflaw, | certify that (check all boxes toindicate your sgreennemG:
OO I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil orcriminal penalties incurreddue violations mfthis
permit.
Q0 The information submitted inthis N0is, tothe best mfmyknowledge and belief, true, acourate and
complete based onmnyinquiry ofthe person orpersons who rnana~ the system, orthose persons
directly responsible for gathering the information.
1 will abide byall conditions ofthe ��mandtheapprovedEroshonand
Sediment Control Plan.
00 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions of
Part |!mfthe permit are met onthe project atall times.
Q� | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Name of Project: LeafSpring School at Cornelius
Legally Responsible Organizational Entity:. Jay D Holdings Cornelius, Inc
—Legally Responsible Person: Jeffrey J. Bazow
Title of Legally
:F *Signature: Date:
m
Individual Differs from Permittee:
Phone Number: 910-930-0460
*IMPORTANTNOTE. Thisform must 6esigned 6vuresponsible corporate o���mtu�scro�m�/d�
con�ruc��ocb�¢is�hosopu�&�n�secne�q<�eosu/e�orv�� —
p/��/den�orornonugsrthat is
authoszed/naozvnoanmewi�/Part /\<Sec�on��/� �Jaf -e vice president,
For more information onsignatory requirements, see Part IV, Section �Item (6) of the NCG010000 permit.