NCC215456_NOI Signed Certification_20211005

NCG01 Notice of Intent (1401) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N I.
Th a n, ma it the original form to the NC DE LR form at r Program (with 100 check if paying by check) at:
[division of Energy, Kneral & Load Resources Stormwater Program
12 N. Salisbury Street, 6,b Floor (Office 0)
1612 Mail Bernice Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPUCATION HAS BEEN ACCEPTED AS COMPLETE.
THE FARM YOU MAIL MUST 8E COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 1I2.22J
Per NC General Statute 14 - 15.6E (i), any person who knowingly makes anyfolse stotement,. repre5entatjon,, or
certification in an y appl cation, record, report} plan, or other document filed or required to be m aintained under this
Article or o rule i plementing this Article ha11 be guilty of o Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars ( 10, 0 0).
0 nd e r pe na Ity of law, I certify that I chec k al I boxes to i nd icate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the re uiremem of this
perrnit, a nd for any civil or cnminaI penalties incurred due to violations of this permit.
The information submitted in this N01 is to the best of my knowledge and l�
�e ref, true, accurate, and complete
ba sed o n my i ng u i ry of t h e pro n or perso n s who mars a ge the system, o r those pe rsons d i rectly respons i ble for
gathering the information.
Se I will abide all conditions of the N O10000 General Permit � � r t and the approved Erosion and Sediment Control
Plan.
If the a pp roped E rosio n and Sed 1 me rrt Contro l Plan i s not compl i a rat with part I l (Storm water Pol l ut io n
Prevention plan) of the NCG010000 General !PerI grill noneth Bless ensure that all conditions of part I I of the
permit are met on the protect at all times.
I hereby request coverage under the.NCGO10000 General Permit and understand that coverage under � this
permit gill constitute the perimit req u i reme nts for the di ch arge(s) and is enforceable 1n the same manner as an
i ndiidual ,perm Mt.
Name of Project (must match A10): HELMS PROPERTY T PILE PLANS
Specific Lot Numbers (must match Alb). N/
- -Lega l l y
Responsible
0 rga n izatio na
I Entity ( must match Bl ):
J S H E LM S FAM I L Y P RO P E R T I E S + L L
Legally
Respo n nil b le
person (must match L72 & s ). B R1 A N
H E L
Title of Legally Responsible Person must match 83bj: PRESIDENT
Name & Title of Signed if Authorized Individual
differs from Legally Responsible Person: /
phone Number- 704.0 58-8804--.,,- z1
Signature of Lea
espon�6e Person ar�'ied Individual
0 / 71 0 1
Date
* IMPORTANT NoTF: This forma must be signed by a responsible corporate officer that owns or operates the construction activity,
Such 0s a P res iden t, s ecretor , ire asurer, o r price p residen t, or a m a n alter tho t is a u th ors d in a ccorda race with Part IV Section B,
Item (5) of the NCG010000 permit.