NCC205011_Site Plan or Location Map_20201105

11 Notice of Intent (1) Certification Feria
Directions;
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the SIC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, MineraI & Land Resources Storrnwater Program
512 N- Salisbury Street, 61" Floor (Office 640K)
1612 Ma11 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 Scoriae 143-215.68 (t), any person who knowingly makes ony false statement representation,
or certiffcatiork iri any application, record, report, pion, or other document filed or required to be mufntained
under this Arti6e or a rule implementing this Article . , , shO be goiity of o 0ass 2 misdemeonor which rrroy
include a f+Me not to exceed terr thousernd dollars ($10, ).
U nder pens Ity of taVUr I certify that (check all boxes to indicate your agreement):
1 I am the person responslble for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal perm lties incurred due to violations of th is
permit,
® The information submitted in this Not is, to the test of my knowledge and belief, true, accurate, and
complete lnd5ed on my inquiry of the person or persons who ma none the system, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the :-I�-G010000 Gencra1 Pen and thre approved Erasion and
Sediment Control Plan.
l if the approved Erosicin and Sediment Control Plan is not compliant with Part II (Starmwater Pollution
Preverrtion Plan) of the NCG010000 Ganera1. Perm;, I wNl nonetheless ensure that ail conditions of
Part II of the permit are rnet or7 the project at all times_
I$1 I hereby request coverage under the VACGC1wI')006'en era I kr i,r, and understand that coverage under
this perm it wiII ccnstitute the permit requirements for the discharges) and is enforceable in the
Same rna+lner as ari individuat permit.
Na me of Project: Dillehay Court Apartments
Legally Responsible organisational Entity; HD Properties, Inc
Legally Responsible Person: Connie Staudinger
Title of Legally R ponsible Person: project Manager
;nature' (-10�r_ ;
° Print Narne and Title of Signed if Aurhor+ d
fndividtial Duffers from Permittee
Phone Numbers 704-3*36-833
Date:
* IMPORTANT NOTE. This form must be signed by 0 responsible corporate aff+cer rho owns or operates the
construction activity, such os a president, secretory, treasurer, or vice president or o rmanoger that f5
authorized in caccordonce with Port !V Section 8, feerrr (6) of the NCfi010000 permit
For more information on signotory requirements, see part IV, Section 6, item (6) of the NCG010000 permit.