HomeMy WebLinkAboutNCC211189_NOI Signed Certification_20210316NCG1 Notice of Intent (NO]) Certification Form
Directions:
Print this Iornl, complete, scan and upload to the ek-cironic N01,
Then, mail the original form to the NC. DEMLR Storniwater Program (v7dth'100 check izpoying by check) at:
Division of Eneigy, lAineral & Land Resources Stormkr�rater Program
512 I`. Salisbury Street, 0"" r100!_ {Office 64011',)
1612 iVail Service Cenier
Raleigh, RtC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215,5B (1), any person kn9wingl31 makes Gny false siuielrreni, repleseniutiori,
Or certification in 01-' y Of pikuiion, recof-d, rel.)ort, 1)[01.1, Or other docun-'enu f Tied Or reQ(dil-ed - o be moini-ah]ed
under this Article or o rule implemeniing this Ariide ... shall be guilty of a Class 2 misdemeanor v'ihich ploy
include Q f111e nuTo O exceed ten T1)Or1cC}11Ci anliOl"5 i$10,000J.
Undler pen_pity of i?14+, i, cert!f�' that (check Gil boxes to indicate youI" a4greem n!):
IS I all) th=- 1-I&I-S n resporisUe 0i- the- conSEruction activil ieS of this pr cjc:C-t, vl' satisfying'L-he
reouiren?ents of This permit, and for any Civil or c0minal penalties inrLirreC due to vioi?tlons of this
pe= .-ill it.
The information suhrniTteo In this N01 is, to the best of my knovdedge and beiief; tale, accurate; and
cornpleie 1. 6--=—d vi) 111`{ II-I-.u;ri' i)I tie person or persons who manage t11E SVStEm, Or ih3sa peI"soils
directly responsible for gathering the information.
f
L I utfill abide by all Conditions di}'the NCGO10000 General Permit and the approveri Erosion and
Se[:iment Control Plan.
t
u 11 llle nhpi"GVcd FrUS!GI"i al';Ci Scuill;cnl Col)tl"OI Hari IS nol Cuii;jsifaV;l Vi/iL;l Pa!'� li {`aL01";-i-i1^,;niCi PC) llUtioll
Prevention Plan) of the NCG010000 General Permit, I will noneti)eless ensure that all conditions of
Part li Of the perrniL are runt on the project at all times.
V 1 1lereb� requ&st coverage under the NCG010000 General Permit and understand that coverage under
thisi101"iilli 1'11}I CGRSCItU' the peril1lt requirements fol"the
diSCh3DCgE(SI al"lu iS ellfCl"Ceal3le Ill the
same 1)i^rl!1C'C as an IndividLlal iiErliiEt.
Name of ProjLct:--
Legally Respansillle Organi rational Entity: H Cor1.Se i
LegaNy Respons l_,le Person:__ griAn l al _ _�-------__ -_� --- --
Title of Legal!',( Responsible Person: �-Act,+
_*Signature: "�Y1A1�4�r_�.►rv-►�+._.. DatE:��..������.��
"Print Dame and i Itle o'! SisFieo i? /1.??+mc,!-7ieE2
ii7d1Y/"dOCl! Lri1rierS ;,1"!iflr elVi? iie'e.
Phone i\1ur111)"I:
C + 01'C5f_%OO-C .c CGliJO1 ': ' G:
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