NCC215029_NOI Signed Certification_20210928

NCGO1 Notice of Intent (N01) Certification Form
Directions.
Print this form, complete, scan and upload to the electronic NOi.
Then, mait the original form to the NC DEMUR Stormwater Program (with $100 checks if paying by checks at:
DivisIGn of energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th 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 ORIGINAL SIGNATURE (NOT DIGITAL) [40 CPR 122.221
Per NC General Statute 143-235.68 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report,plan., or other document �iied or required �o be maintained under thrs
Article or a rule implementing this Article... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed #en thousand dollars
Under penalty of haw, i certify that (check all boxes to indicate your agreement)-
4
� 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.
21 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
fathering the information.
IX I will abide by all conditions of the NCGDIDDDD General Permit and the approved Erosion and Sediment Control
Plan.
� If the approved erosion
and Sediment Control Plan is
not
compliant with Park
11 (Stormwater Pollution
Prevention Plan) of the
NCG010000 Genera[ Permit, l
will
nonetheless ensure
that all conditions of Bart it of the
permit are met on the project at all times.
�f I hereby request coverage under the NCGO10000 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 ATa):
Harman
Specific Lot Numbers must match Alb)..4h
Baptist Church
Legally Responsible Organizational Ent9tV (must match B1): Harmony baptist Church
Legally Responsible Person (must match S2 & 133): Dean Stillman Alle
Title of Legally Responsible Person (must match Bab}: Church Treasurer
Name & Title of Signed if Authorized Individual
Differs from legally Responsible Persow.
Phone Nuer_ 252-331-1002
lz
Signature of Legally Responsible Person or Authorized individual
IMPOTT NOTE:
This form
must be signed by a responsible
corporate officer that owns or operate5 the construction activity.
such os a pre-5ident,
secretary,
r# or vice- r a
m anag er th at is a uthorized in ac o rdon ce withPort t V, Section 8,
Item (6) of the NCG010000 permit.