HomeMy WebLinkAboutNCC205357_NOI Signed Certification_20201124NCG41 Notice of Intent (NOI) Certification Form
Directions:
Pi'irit this form, complete, scan and upload to the electronic. NOI.
Then, Ilan the on nal tc?I m to the NC: DEilKR Stonllvl+ater N-og2"i m [vith $100 checi(ypaWny by check) at:
Division of Enc-rg;+, Mineral & Land Resources 5tcrllly,+ater Program
512 i'•,I. Salisiimy Street, 6-' Floor (Office 6 0K
2612 i1"ail 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 General St-otuie 143-215.6u (i), any person who knovilingl}% i tikes a17y folse st,7zeme!7 , reprecentotion,
or cerlijkabon in ony applicaito;7, record, report, plan, Or other to be mamtamed
under this article or c rule ?niplementing this Atticle ... Wall be gout)/ Oj` u' Clc7ss 7 nnisCerreol70r vilhich moy
include a fine not to eyceed fen thousand dollars ($10,000).
Under penaky of law, I rC:"iif;f that (check all boxes to indicate yaw agmemelQ
I am the person res"ponsibie for the construction activities of this projEct, for satisfying the
requirements Of, this permlt, and for any civil or cril hi l penalises incuued due to vibations of Gs
oerllill..
The in'or1-?ati011 sUbmittLd ill this NO! Is, to the best of my knmWedSe ard. be!iC- , tf''e, a.CCl!rate, and
complAE band cn my lnply of ire pemon or pusOi15 No manage file systen , or those persons
directly respons N for gathering the information.
s�r i %will abide by ail wndAbns of the NCG010000 General Permit and the a proved Erosion and
/ Sediment Control Tian,
n " Er SEdi Control Plan is not con"' Hantwith, Part ii SCOS'rli�+vd cl" i-`� ftdiGn
I�I tide apNro'Jcci Citl�ititli ar�u cuilliclli: 1
Prevention Plan) of the NC6010000 General Permit, ! oil nonetheiess ensure that all conditions of
Part II of the perniii are islet on the project at all times.
I herby raquest coverage under the NCG010000 General Permit and understand that coverage under
this penvit U'A constitute the permit re-( Ldvements for the clisCr, ey and K EnforC£aNe 5 the
same nwnmr as all individual permit.
Naille-of F€_ojert: ti v� -IA- Q '11 off, car —1 2, /i - / r — --
Legaly Responsible C}rgani; aticna! Fntii)+;'�}} COnS�`Y11��
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Legally Responsible F'ersnn: _ }{` ox) 1 �� 1 .` ----- ----------- --- ----
TMe of QgAly Reslmns e Person:—
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XSig,nature-VI..�
%'Print Name and ' !1:1e o': S j'ieLt 0.rk!-'i1 oNed
inCl1�!dtllilLr"r7=fs
Phone l`:lllill7er:
WKWA10146,70 Lm K skned b,ares..oWN copowfeq1'.tu sms i• .,.'_rnestl',e
ouugn Apo 0, i+Ct'&r'; ur 0 T1 Al!! W ii_f'r+i ) 3. Hem M) Gjrili, iuCG 1G00Grlrlf+'T
For ,_ -� - - , Vtoner see For11! -_-- .--._:...r
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