HomeMy WebLinkAboutNCC205001_NOI Signed Certification_20201104NCG01 Notice of Intent (NOI) Certification Form
Directions:
Pl-il"it this '101-171,r cornplete, stall and upload to the electronic N101.
Then, mail the original lord', to the N'C: dEl'1,11_R Stormwater Prograrn (v,,ith $100 check if paying by check) at:
Gi'v, ision of Eticrgy, I\iinerai & Land Resources Stormvv'ater Program
512 N. Salisbury Street, 6`" Floor (Office. 640K)
1612 Ilr!ail Service Centel -
Raleigh, N IC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
r
Per AIC Ge!;eral Statute 14.3-1215.6B (i), ony person who knowingly mokes Gny folse Sfil.ter7lelif, 1"epl'eEen Gt1D11,
or certificotion in any Lpp),lcatlCll, record, 1`C1)ort, Plai1, or other docLll?7s;nP filed ol.?"equired to be niointail7ed
tinder this Article or" o rule this Article ... shall be guilty of aClass 2 noiscerneonor tvhich may
include o fine not to nrcee( felt timusarld dollars (W,000).
Under re:-alty of 12',`tir, 1 ce:",if)' ha'i (cited; all boxes to indicate your agr' creptt):
I am talc per5Gn rEsponsibie for the construction octivi'ties of this project, for satisfying isle
rer'uirements & this I?errnit, and for any civil or criminel henc.ltles incurred due to violations of this
!Del .ii iT..
The IilroPI! atiG!? 51.1h- 11Tted in this N01 is, to the nest of my knowledge ar'Cl' helm?", l!" '.e 2ccl.lrate, 2nd
- S" i + o-=ham S I <<Ei i�5c per5o} s
COnlf;;_a I;a �u „il illy lii:yuil"j f,i,� pcl'5011 CI" 1.crS4i"t 'J;+r1G Iiluna4E'tic 5)., li, cr l'
directly respons'ib!e for gathering the information.
f I Mil ab;lde by aii condlfti0ils of the NCGO10000 General Permit and the approved Erosion and
Sediment%ontrol Plan.
If appl"G'dcu Civ i�r �r'd sedililen% Cc'ntl-ol Plait Is J10t LCiI'filiiai"i VVilil} Fal"i it tiStCW.-I- hia ET P0111.ttioll
Prevention Puri) of the NCG010000 General Permit, I will noJietheless ensure tha-i all conditions of
Part ll of the permit are met on the project at all times.
1 hefc_—ID : request coverage under the NCG010000 General Permit and unaersiand that coverage under
will co-listiMe the permit requirements foi' Che disci",-': e(S) and Is cillorceaiile in he
same illal'1112r aS al-- Iildlvidl-lal permit.
Narile-of Project; _ �02A 009
Legally Responsible Oremnizationai Fntit:y:
Legally Responsible Persr�n:— )r i#.n '�, akq� — ---- -------------_m_��._
Title of Legally R.zsjxnsihle Perso,l: `tni,
*Signaturee� Ua�e: 202�
"Print I'mme and i1ie G-; CicrloO rl. r?L!thOft e[C
PIICi"ie I\U<'lliSe C� lj " �'i (0-Ll G b4
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