NCC205484_NOI Signed Certification_20201210

NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, nnaU the original form to the NC DEK4LR Stormvvater Program (with $100check /fpaying bvcheck) at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
51ZN.Salisbury Street, 6mFloor (Office 64OK)
lGl2Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143Q25.6B(i),any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article urorule implementing this Article ... shalt beguilty ufoClass Jmisdemeanor which may
include mfine not toexceed ten thousand dollars ($20,000).
Under penalty oflaw, | certify that (check all boxes toindicate your agreennend:
'" |annthe person responsible for the construction activities ofthis project, for satisfying the.
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
��
�� The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete based ommmy inquiry ofthe person orpersons who manage the system, orthose persons
directly responsible for gathering the information.
V I will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project otall times.
| hereby request coverage under the NCG010000 General Permit 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 ofp /\lfOOSO BeOGVidBZ Lots 1 5
Legally Responsible Organizational Entity: Alfonso BoRav44oz r k/,- 2v le 2-
Alfonso Bermvidez A
Title ofLegally Responsible Person: []VVOer
*Signature: 51
*Print Name
.
Title of Signed if Authorized
-*,hone Number: 919-599-8666
IMPORTANT NOTE: Thisform must be signed byoresponsible corporate officer that owns moperates the
construction activity, such usopresident, secretary, treasurer, orvice president, orumanager that /s
authorized in accordance with Part IV, Section B, Item (6) of the NCGO1 0000 permit.
For more information onsignatory requirements, see Part IV, SectionB, Item (6)of the N[G00000permit.