NCC213764_NOI Signed Certification_20210714

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 check) at:
Division of Energy, Mineral & Land Resources stormwater Program
512 N. Salisbury Street, 6t'l Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINALS A OT DIGITAL) [40 CFR 122-221
Per NC Genera/Statute 143-215,6B flJ, any person who knowingly makes any false statement, representation, or
certification in any opplication, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10, 000),
Under penalty of haw, I certify that check ail boxes to indicafie your agreement):
� I am the person responsible for the construction activities of this project, for satisfying the requirements o
permit., and for any civil or criminal penalties incurred due to violations of this permit. p f this
The information submitted in this NCI is, to the best of my knowledge and belief, true., accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information. p
� 1 will abide by all conditions of the NCGO10000 Genera-1 Permit and the approved Erosion and Sediment Control
Plan.
� If the approved erosion and Sediment Control Plan is not compliant with Part II Stormwater PollutionPrevention Plan) of the NCG010000 General PermitI will nonethBless ensure that
all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that covera e under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the ame manner as
individual permit. an
Name of Project (must match Alo): Medlin Forest Subdivsion
Specific dot Numbers (must match Alb):
Legally Responsible -Organizational entity (must match 8.1): Dream Finders Hornes, LLC
legally Responsible Person (must match 132 & B.).. hack Rostetter
Title of Legally Responsible Person (must match b): Regional Divisional President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number.- 980-2671-
Signat e of
IfRe'
o`n-s-Fb.1e—P--et=son or Authorized Individual
Date
x IMPQRTANT fllOTE: This form must be signed by a responsible corporate o
such as a president, secretary, treasurerfficer that owns or operates the e construction activrty,
Item (6) of the NCG010400 permit. , ot� vice president, or a manager that is authorized in accordance with Part 1V, Section B