HomeMy WebLinkAboutNCC205006_NOI Signed Certification_20201105NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print- this tDrrli, cornplete, scan and upload to the elecicrolslc N01.
Then, alail the original turn to the NC DEKIM Stomiwater Prograrn (vvfith $100 check; if paying by check) at.
Division of Enc-rg'y, kllnerai I&; Land Resources Stormwater Program
512 I''t. Salisbury Street 6`r, Floor (office 6A01()
161.2 Mail Service Center
Raleigh, NIC 2-7699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Stotute 143-211.7.6S 011, any pplSon who knowingly drakes ally false sta-L'el?JE':`le, 1'ep1'esentot10ll,
or cei-Qication in ony ap kotio;l, record, report, plan, or other doctlf"I enz- fiifed orrecuired to be nio ll?alnea
under this Article or a rule in)pleni2nfi1)g this Article ... snail be guilty of a'Class .2 misoerl eonor t.vh1ch may
include o fide not to e,-ceed ten thousend dollars ($10,000j,
Under penalty of la1v, ! Ce:" il';r 1?C (check all boxes to indicate your a-rc-e mer-40:
V I am tiio hers3n rEsponsible for the Construction activities of ii1,s projEct-, 101- Satlsfying ine
regUirements of This ;lDeri-r0t, and for any civil or criminal Penaitles incijned duW vioiations of this
e Y:�9 ' 'l S r ; ! i a r tr �cr p � elief, PUe aCCU r d
_ Th Ii1=C, �.at;o,. L hllitt_'� n this �QI is, to file best of m; I !10 ,•i c� a!'�d l7 :r_.; t, L-t, �:r•at..; 2n..
COn'li�l'i� l7ased Cif lT:L !lit uiL y ^.f file person or persons vJho manage the s''plsteill, or tllluSC pei'so!iS
directly responslb'e for gathering the information.
f i valid abide by, ail conditions of the NCG010000 General Permit and the aow,ovred Erosion and
Sediment Control Fiat-,.
If the c roved Cri Jii - nd SedIl-'eIi�i P
'i7ii Cuiltrol Pi"'al1 Is Ilot CL?Il'llt§slit i+vitl"i ral'i iI tSioi'il-fllvaicl" FoiILItIDIi
Prevention flail) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part Ll of the porn-iiL are me;: on the project at all times.
I herebv request coverage under the NC6010000 General Permit and understand L.hat coverage under
this uern', will constitute the permit requirennents for "rhe disC'i"iar- eisl and Is e;l c•rcealile in the
Sable lilal"MEC aS Atli Iildivid-Lial permit. -�-k-p -oH
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Nan1e-ot Frojert: 2- -31-433, 4 39 .4-2 . q3, 45,19 SIB 5Z-5-5, s 7, (f Q tal. Cow]8 -,32
Legallyf Fesponsible Orn31117?tlGl1r I i ntitl`; 1F r -Sr pv(1 SC !� �r nQ- •
_I_egall�;r Resiaonlil,le r,erson:---------
Title of Legally R-esp'onsiWe, Person, ,
*Signatur_'=--�yti,.+frer 1� - — Date:
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