NCC216271_NOI Signed Certification_20211110

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original 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, 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 CFR 122.221
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 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 project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
❑x 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 compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
® 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 Ala): Gillings Property (Capital Associates Property)
Specific Lot Numbers (must match Alb): 0757-38-3772, 0757-28-76-6969.DW
Legally Responsible Organizational Entity (must match B1): Pleasant Grove Warehouse LLC
Legally Responsible Person (must match B2 & B3): Frank Baird
Title of Legally Responsible Person (must match B3b): CEO,
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-233-9901
Signature of Legally Responsible Pers'nIn
or Authorized Individual L1_C
Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 permit.

STORMWATER DEPARTMENT
ENVIRONMENTAL GRADING PE
Permit No.: LD-21-24 Approved By
Comments: EARLY GRADING (REVISED) Fee: $5,400.01
Permit Issue Date: 08/30/2021 Affected Basin:
Denuded Area in Acres: 10.8
This is to certify that Pleasant Grove Warehouse LLC has received approval from the Town of Cary
to engage in land disturbing activities at Gillings Property (Capital Associates Property); 21-DP-
7936
Location: 3615 Pleasant Grove Church Rd.
This ENVIRONMENTAL PERMIT is issued and accepted subject to the following conditions:
1. All soil erosion and sedimentation control devices shall be installed in accordance with Town of
Cary Standard Specifications and Details.
2. The Town of Cary may inspect the site at any time following the issuance of this Permit and may
require additional measures to be installed in lieu of or in addition to those measures shown on
the approved Soil Erosion and Sedimentation Control Plan where deemed necessary.
3. Grading permits that denude one or more acres must comply with the National Pollutant
Discharge Elimination System. This grading permit covers you under the general permit
regulated by the State of North Carolina Division of Water Resources.
4. Applicant must call 460-4934 or 462-3886 for an on -site inspection and receive a CERTIFICATE
OF COMPLIANCE for Soil Erosion and Sedimentation Control prior to proceeding with site
grading, utility installation, and building permit application.
5. A copy of the approved Soil Erosion and Sedimentation Control Plan and this Permit must be
available on -site at all times.
6. Any failure to execute the provisions of this permit, the approved Soil Erosion and Sedimentation
Control Plan, or any other provisions of the Soil Erosion Control Ordinance shall result in
immediate legal action by the Town of Cary to the limits prescribed by the Ordinance.
I hereby acknowledge and accept all conditions of this Permit as listed above.
To. � llama ►d -Z( -X620
Signature of Permit Holder Date
Representing
Receipt No.
TOWN O/ CARY
By:
316 North Academy Street • Cary, NC 27513 • PO Box 8005 - Cary, NC 27512-8005
te1919-469-4030 - fax [phone]• wwvv. townofcary. org