NCC215293_NOI Signed Certification_20210927

NCG01 Notice of Intent (1401) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the.vriginal 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, f=h Floor (Office 540K)
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 ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122121
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,, or
certification in any appfication, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article. shaJl be guilty of a Cass 2 misdemeanor which may include afrne not to
exceed ten thousand dollars ($10,000).
Un r enalty 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.
The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and complete
bayed an my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
! will abide by all conditions of the NCGa1O000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
Preve ntion Plan) of the NCGG2DDO0 General Permit, I will nonetheless ensure that all conditions of Part If of the
permit are met on the project at all times.
l 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 (must match Ada}: Davis Lot 2
Specif ic Lod IVumhers must mach Alb}: 2
Legally Responsible Organizational Entity (mush match B1): Lawrence Homey Inc.
Legally Responsible Person (must mach BZ & B3)-. Lawrence Langer
Title of Legally Responsibly Person (must match 8.3b): VP
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Pone Number: 919-528�-7767
4p,
OW
5ignat e of egally Responsi e Person or Authorized Individual
9/17/21
Date
IMPORTANTNOTE:
This form
must be signed by a responsible
corporate officer that owns
or operates the construction activity,
such a o P r ] den t,
secretary,
tre as u re r, o r vice Pre.5ide t, or cr
manager t of is authorized
in accordance with Part IV, Section B,
Item (6) of the NCG010400 permit.