HomeMy WebLinkAboutNCC205816_NOI Signed Certification_20201217NCG01 Notice of Intent (NOI) Certification Form
Directions:
Prim this lorrl; cornlyete, scan and upload to the Elecironic I\Io;.
T hen, mail the original i` no to the NC DEMLR StorniwMer nogram (wKh �1.00 check if paying by check) at:
Division of En&yy, I'vlinerai &; Land Resources S"io!aiwater Program
512 It Salisbu T Street, 5-1' Floor (Office G!0K)
1.61.2 Nlai[ Service Center
Raleigh, NC 2769%1612
DO NOT MAID THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Pei, NC General StGiute 1z,3-21.7.ES (i), ony person Who knoilvingly mokes arty false sto-,emten , representation,
or certiflcrotion in any ajJpkotion, record, repol-, plait, or other docun??r7E fi/ed or required to he nictintained
underthis Ai iicle or a rule in)piemenfing this .4ri" & ... shall be guilty oj` sw'Closs 2 n7isderneonOr- ir,!hich may
inch"de a fine not to pYCeei7 Ten th-oi;'Sond dollars ($10,000).
Under pen aIt,f A law, I ce: ly t: at (check a I I boxes to MdWe you agreek11vQ
I aril thperson Icsponsible fDr the construction act vR&s of this proj&a, for satisfy'iFig 'ihE
re-,Lftements of this permit, and for any civil or crirnincl penF (ties ?ncur rpdl due to vitiations of this
pemlit.
The hi? ornnaidon SLIlbillilted in this I\I0l Q to Me best of my knWed-es and heliet t!-t.'.E', 2cCLrrat'e; 2nd.
Cornpl: ite IlusE cn it-iy iniquiryi of the person or persons. 4':ho manage th= s1+Stull, or thisc-- persons
dlectly responsibb for gathering the Aformation.
i MIJ guide by A cond%ns of the NCGO10000 General Permit and tl<e app;'oved Erosion and
�y� Sediment Control Plan,
If the appCOVEd C31.�,� on and Sedilvani Control Mail Is not colt pli Slit'tiitilh Part l (StDrrlillv�icl' rvllLrtiul1
Prevention Nan) of the i\ICG010000 General Permit, I will nonetheless ensure that all conditions of
Dart Ii of the porn -,it are met on the pi-o]ect at all times.
I hereby requesi coverage under the NCG010000General Permit and understand [hat coverage under
thk pensk L'vlii constitute the permit req'uiremic-nits for'Lhe disci aire(s) and Is enl orceable in the
sa llr riidllnci as t r, individual permit.
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Legally Responsible Organizational Entity: ��r�' C.0'v5tyv%'"Y'�
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Legally Responsible Person:-
TNe of Lcr;My Regnnsihle Person:
Dam: I Z 2D2.0
I'R!"int Name and fit!e o:' DSO•"teCi ?; :�.L'£i70.'"!ZeLi
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