NCC210615_NOI Signed Certification_20210203

N CG01 Notice of Intent (N01) Certiftcatlon Forr>r>`
Direct -tons;
Print this form, corn plete, scare and upload to .he electronic Not.
Then, mail the original form to the NC DEMLR Stormwater Program (with $3.00 check if paying by check) at;
Division of Energy, Minerai & Land Ruaij rces Stormwater Program
512 N. Salisbury Street, 6Lh Floor (Office 640K)
if 12 Mail Service Center
RnWig h, NC 27699-161 t
DO NOT MAIL THIS FORM OR PAYMENT
UN7fL YOUR APPLICATICNU HAS BEEN REV IE >:D AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.GB (rJ, ornyperson who knowingly rookes any false statement, representatiorn, ar
certification in arty opplication, record, report, pion, or other document fired or repaired to be maintofned under this
Article, or g rule implementing this Article ... shuii be guilty of a Gass 2 misdemeanor which moy include a fine not to
exceed ten thousanddoflars( 10,OM).
Under penalty of law, I certify that (check all boxes to indicate your agreement);
am the person fesponsible tar the construction activities of this project, for satisfying the requirements of this
permit, and for arty civil or criminal penalties incurred due to violations of this permit.
The information Submitted in this NO is, to the best of my knowledge and belief, true, accurate, and complete
rased on my inquiry of the person or persons who manage the systern, or those persons directly responsible far
gathering the frrform;Won.
1 will abide by all conditions of the NCG010000 GerneraI Permit and tyre approved Erasion and Sediment ContraI
Plan.
If the approved Erosion and Sediment Control Na n is not compiiant with Part 11 (Stormwater Pollution
Prevention Plan) of the MCG010" General Permit I will nonetheiess ensure that all conditions of Part 11 of the
permit are met on the project at all times.
sr I hereby request coverage under the NCG010M General Permit and understand that Coverage under this
permit wiII Constitute the permit requirements for the discharges) and is enforceable in the saute manner es ;�n
individual permit.
Brigham Ridge Apartments
Name of Project (must motch Ala)
Pleasant Ridge -Brigham, LLC
Legally Responsible Organizational Entity (mustmotch 81)
Kevirk Phillip,.
Legally Responsible Person (most rrrarch B2 & 83)
Managing Member of Pleasaint Ridge -Brigham, LL
Title of Legally Res ble P erson (must rrigtch 83b)
gnature
Date
* Print Name and Title of Signed if Authoffzed Individual Differs from Legally Responsible Person
Phone Number
* IMPORTANT NOTE. This farm must be signed by or responsible corporate Officer that awns or operotes the consfrvcriotr aceiui ty,
such as o president, secretory, treasurer, or vice presidertL or u manager that is authorized rn occardarwe with Port +V Section B,
item (61 of the NC 010000 permit: for more informatforr on sigpertary requirerrrerrts, see Port � V Section B, irem (6) of the
NCC010000 permit_