NCC212677_NOI Signed Certification_20210511

NCG01 Notice of I ntent {N01) CLrtifieation Form
Directions:
Pr61t lids form, Complete, scan and upload to the electronic NOI.
Then, mall the aristirrJi form to the NC OEMLR Stormwater Program Iwnh $lDD cheek Jf paying by Clietk7 a --
Ltivisian of Frrerry, Mineral & Land Resourcis Stormwater Program
512 M. Sallsbury Street, 01 F7oor (Office 6e0k7
1631 Mail Sarvke Center
Raleigh, NC 27699-1612
DO FfOT MAIL THIS MRM OR PATMILNT
uNTIL YOWA APPLICATION MS (SEEN REVIEWED AND ACL£PTEO AS CDMPIETE
per ilCCenerOe.Statudeid3-21S,58pJaaypersonwho kn&wiApJymakes a+syfa?sCitaremenErepr ntatian or
rertyrirork n 0 ony appJ&Gt.OM mod report, pilen or adwr do[wnreM flied or "i ed to bE moinrOinCdr+,ader this
ArN:k ova rLdt impkn1entiP9 this Artkft shw4 be grroty aka CAM 1 misdrmeaow FmIch copy b-eude a ftnC no to
exceed tea th w-wrd diowrs 610,WO1.
Under penxiy of law, I te" that;Ohtek all bores to Indicate Your a&rtn+nsntf:
I am the person rrspourslbW for the conseructiam activities of this protect. for satlsfying the requiremwents Of this
permit, and lot any civa or inmtnal penalties Incurred die to rriotations of this peemil.
The information srAimAted m this MOO Is, 10 the Crest of my kno4e4& and belief, true, accurate, and complete
cased an my inquiry of the person or persons %tea manage tt•,r system, or those persons direcitr responsible for
gathering the Information.
I will abide by all (OnNions of tine and the approved Erosion and Sedi mcnt Control
Plan
It the apprcrerd Erosion and Sediment Control Plan is rwI complian r with Part It {5twrmwater Polleian
Prevention Plan] of the NC0010000 GenrraI PermiL I Will nonelhetefs ensure that all conditions of Part 11 of the
permit are met on the project at all times,
I hereby request coverage under the NCG010000 fitnc ral Per and understand that carerage and er this
permit will constitute the perrrrit requirements for the disoharge(s] ano is enftrrceahAe in the same manner as an
ineWidual permit.
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Specific.i� C�CJ�1 rim O � � c}
Lot Numbers(mustmaInAlb): 573
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wally Responsible Ptr-wn fryrust motclr 818r M- R—
Title of Legally Responsible Person {rrwsr nwfrh fiJb}: ( E .S I' e Y—
N me & Title of Signed If Authorized Individual
Differs from tega►y R�nsiNee Person: C} ? /}
Phone Number: —9 1-9- b ` 5 Q C) O`*
Ignature rNaihle Pprian pr l IiN ned Ind old ial Elate
•ASVMANT WTIF: THs farm musr be rdpned by+a rrsyan Wr rowmre Off cel ehad awns aropeeves the consrnrction acm4rry,
*96 as aprtsident, mcfein, treatww, ar wepreWOM, Or d M"OW rhat is a;alhoriyed in occordonce width Fart h{ iectka
1t m (6) pf rlsr NC601 D00 perrnk.