HomeMy WebLinkAboutNCC215026_NOI Signed Certification_20210908DocuSign Envelope ID: 580BF18E-DFC4-4865-A786-942023DE73OF
NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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, 61" 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 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed 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 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
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
0 The information submitted in this NOI 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.
0 I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
IR If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: Blythe Blvd. and Medical Center Dr. Improvement Plans
Legally Responsible Organizational Entity: Atrium Health, Inc.
Ilv Responsible Person: Robert Speakman
Title of Legally Responsible Person: Senior Project Manager
Docu ,ig by:
*Signature: r?Z SpuAMau, Date: 09/02/2021
�ewnazcocaannns_.
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 704-355-7195
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
DocuSign
Certificate Of Completion
Envelope Id: 580BF18EDFC44865A786942023DE73OF
Subject: Please DocuSign: NCG01-eNOI-Certification-Form
Source Envelope:
Document Pages: 1 Signatures: 1
Certificate Pages: 2 Initials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
9/2/2021 1:36:46 PM
Signer Events
Robert Speakman
robert.speakman@atriumhealth.org
SPM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Certified Delivery Events
Carbon Copy Events
Alex Kimbrell
Alex.Kimbrell@kimley-horn.com
Kimley-Horn
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Cauley Hobson
Cauley.Hobson@kimley-horn.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events
Notary Events
Holder: Corbin Clemons
Corbin.Clemons@kimley-horn.com
Signature
DocuSignetl by:
E
O�t V{ Spt AMA1n
B97432COC83A4A9...
Signature Adoption: Pre -selected Style
Using IPAddress: 161.69.113.33
Signature
Status
Status
Status
Status
Status
OPIED
COPIED
Signature
Signature
Status: Completed
Envelope Originator:
Corbin Clemons
401 Fayetteville St.
Suite 600
Raleigh, NC 27601
Corbin.Clemons@kimley-horn.com
IP Address: 34.99.124.178
Location: DocuSign
Timestamp
Sent: 9/2/2021 1:40:52 PM
Viewed: 9/2/2021 3:08:35 PM
Signed: 9/2/2021 3:09:03 PM
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Sent: 9/2/2021 1:40:53 PM
Viewed: 9/2/2021 1:41:24 PM
Sent: 9/2/2021 1:40:52 PM
Timestamp
Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent
Certified Delivered
Signing Complete
Completed
Hashed/Encrypted
Security Checked
Security Checked
Security Checked
9/2/2021 1:40:53 PM
9/2/2021 3:08:35 PM
9/2/2021 3:09:03 PM
9/2/2021 3:09:03 PM
Payment Events Status Timestamps