NCC216036_NOI Signed Certification_20211029

NCG01 Notice
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Storm ater Program at:
Division of Energy, Mineral & Land Resources Storm ater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Pe NC General Statute 143-215.6E (i), any person who knowingly makes a y false statement, representation,
or certification in any application, record, report, plan, or other document fled or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a lass 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 roject, for satisfying the
requirements of this permit, and for any civil or criminal penaltie incurred due to violations of this
permit.
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.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not complia
Prevention Plan) of the NCGO10000 General Permit, I will noneth
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit
this permit will constitute the permit requirements for the discha
same manner as an individual permit.
Nailne of Project: Governor's Club Lot 80
Ily Responsible Organizational Entity: BOLD Construction
* Legally Responsible Person: Jason Dell
Titl�- of Legally Responsible Person:
Signature:
* IM ORTANT NOTE: This form must be signed by a responsible corporate
construction activity, such as a president, secretary, treasurer, or vice pre
authorized in accordance with Part IV, Section B, Item (6) of the NCG010(
For (more information on signatory requirements, see Part IV, Section B, li
t with Part II (Stormwater Pollution
less ensure that all conditions of
nd understand that coverage under
;e(s) and is enforceable in the
Date: 10/27/2021
Fcer that owns or operates the
?nt, or a manager that is
permit.
(6) of the NCGO10000 permit.