NCC211663_NOI Signed Certification_20210329

N CGO I N oti ee of I me nt (N 0I) Ce rtrfitcation Form
Vfrwions:
Print Thir, ff.Wm, cOrnPk1e, Scan Gild Upltxad Lo the eilectranic N0 L
Then, snail the original Baum to the NC DEMkR �Aorrnwat�r Program (with 5100 Lbuck if poyrr?g by c�mck) at:
Division of Energy, Mineral & Land Resources 5`torm"er Progarn
512 N- Salisbury Street: Sit Flonr(Wice K)
1612 Mail Serwine Center
Raleigh, NC 27699-1612
DO NOT 1VUU L THLS FORM OR RAYMFNT
UhML YOUR APPIJiXnON HAS BEEN REVIEWED AND ACCE PIED AS COMPLETE
Per MC Gerrerad 5#arube 143-215.66 (rj, any pFrsorn who knnwrrrgiY Makes any f ls.& stxrt�merr� Y�Crt�S�vtt�lirarr, yr
cer4ftcatiarr i" any fwlicadion, record, rePor- parr, 4�kr otherdocVlii? ntfi2iod w Fed oyed to be r'nwntaine+d urmder this
Article or a rLOe inWernenrirng this Ard e _ _ _ shaft he g0ty of a Class 2 rrrisa err+ arror whiter miry ir0ude a firm not €o
occ edtEn thouasand"kn�-
Udder penalty of law, I certify that (Chetk aiII Wx W inditdte your a Meint):
® I am the person rerr9ible for the construction activities of this PrDjed, for satingthe requirements ofthis
perm it, and for any civil ar criminal penalties incurr$d due to violatfws of this permit,
® The information 5ubrrritted in this N01 is, to the hest of my knowledge and belief, true, accurate, and complete
based an n-ty inquiry of the person or persons who manage the system, or thgse per5vrr5 directly responsible for
gathering the I rrformatian-
HI I wdI abide by alt conditions of the NC&Ot000D General Permit and the approved Ermion and Sediment C6ntrol
Plan.
Ff the approved Erasion and Sediment Contra Plan is not cpmpliant wkfi Part 11(tormwater Pollutfon
P7evention Man) of the H03101? O General permit, I will nonetheless ensure that all conditions of Part I I of tfte
pevm it arp- mot on the project at all #ime5,
® I hereby request mverage under the N,CCQQ10000 ge nera I_PeM) it and understand that coverage under this
permit will cons-titutetheperrnit requirements for the diwharge(s) and is enforceable in the same manner as an
indmw ual permit
Name of ProjBdt (mristmatrhMa): Hillorest Subdivison
Spe(Ze Let l~Iumbm (muss motchA3b): WS 1-50
Legally Responsi-ble Organizational Entity {must +crotch Erq- ARS H I I IOo{est Develom ink LLG
telly Respansi b1e f'ersarr rx�at & �3�: H artlfatot m ith
Ti-tile of Legally R,es onsibfe Person f must rr o" 83b): Ma naflCF
Name & Tittle of Signed if Autl prized individual
Differs. from Legaltw Responsible Persow
Phone Number_ Lots 1-50
Responsible Person or Authotl zed IrLdlvidual
Date -
IMPORTANT NOTE This farm must be srgne4by a responsible corporate affi--er that owns or operates the co sU ureteon ac W V,
such as a President, seuetaT, treosarer, or -ice pra5ident, or a manager drat b authorized ra accordance with Jet JV, -�--cbm 17,
�krT f15)o1 thc RCOMOOM peirrrR.