NCC210384_NOI Signed Certification_20210125

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check at:
Division of Energy, Mineral & Land Resources Stormwater Program }
512 N. Salisbury Street, 611 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCENTED AS COMPLETE
Per NC General Statute 143-215.6$ O, any person who knowingly makes any folse statement, representation, or
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor
in any application, record, report, plan, or other document filed or required to be maintained under t '
eanor which may include a ine not
to
exceed ten thousand dollars ($10,000). f of t
Under penalty of law, i certify that (check all boxes to indicate your agreement):
® 1 am the person responsible for the construction activities of this project, for satisfying the requirements permit, and for any civil or criminal penalties incurred due to violations of this permit. q eats of this
The information submitted in this NOf is, to the best of my knowledge and belief, true, accurate an
based an my inquiry of the person or persons who manage the system, or those persons directly res onslbl
d complete
gathering the information, p e for
® i will abide by all conditions of the NCG010000 General-� hermit and the approved Erosion and Sediment
ment Control
�I If the approved Erosion and Sediment Control Plan is not compliant with Part i! (Stormwater Pollution
Prevention Plan) of the NCG010000 GeneraI permit I will nonetheless ensure that all conditions of Part 11 of
Permit are met on the project at all times. the
® 1 hereby request coverage under the NCGf)1000
permit wil0 General Permit and understand that coverage l constitute the permit requirements for the discharge(s) and is enforceable in the same manner as a
individual permit.
n
Piedmont Concord Lake
Name of Project (must match Ala}
�Dendable Develo ment, Inc.
Responsible Organizational Entity (must match chael Foess
Legally Responsible Person (must match B2 & B3)
Ops ar n�sn�sible
Title Le ly Person (must match 83b}
*SignatV(ie 01 / 19 / 21
MichaelToess, Dps Partner date
*Print Name and Title of Signed if Authorized Individual Differs from Legally Responsible Person
704-491-3256
Phone Number
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that awns or operates t
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with Pa
rt Item (6) of the NCG010000 permit. For more information on signatory requirements, see Part IV, he construction activity,
NCG01000Q permit. if Section B,
Section 8, Item (bJ of the