NCC212540_NOI Signed Certification_20210519

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by ch
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h 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 ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representat,
certification in any application, record, report, plan, or other document filed or required to be maintained 1
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® I am the person responsible for the construction activities of this project, for satisfying the require
permit, and for any civil or criminal penalties incurred due to violations of this permit.
IX The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, a
based on my inquiry of the person or persons who manage the system, or those persons directly n
gathering the information.
® 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sedi
Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollui
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
permit are met on the project at all times.
® I hereby request coverage under the NCGO10000 General Permit and understand that coverage ur
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same
individual permit.
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Namme of Project (Must Match, A10): `!anceyville Apartments
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match B1): Hunt Development Group, LLC
Legally Responsible Person (must match B2 & B3):
Charles Overby
Title of Legally Responsible Person (must match B3b): Owner I i
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 336-471-7835
j
Signature of Legally Responsi a Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construclt ion activity,
such as a president secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part , lsection B,
Item (6) of the NCGO10000 permit.