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HomeMy WebLinkAboutNCC215029_NOI Signed Certification_20210928NCGO1 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.