NCC216969_NOI Signed Certification_20211216

NCGO1 Notice of Intent (N01) Certification Form
1
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 Storrnwater Program
512 N. Salisbury Street, 6,h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NET MAIL THIS FORM 4R PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 121221
Per NC General Statute 143-215.6B (i),. any person who knowingly makes any false statement, representation, or
certrfrcatron in any application, record, report, plan, or other docum en t filed or required to be maintained under this
Article or Q rule implementing this Article ...shall be guilty of a Class 2 misdemeanor which may include a dine not to
exceed ten thousand dollars ($10, 000).
Under penalty of law,, I certify that (check all boxes to indicate your agreement):
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.
The information submit#ed 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.
will abide by all conditions of the NCG010000 General Permit and the approved Erasion and Sediment Contra
Phan.
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 If of the
permit are met on the project at all times.
VI hereby request coverage under tie NCGO1n000 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 Rya}: Broadstone South End
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity {must match 131): Alliance Realty Partners, LLC
Legally Responsible Person must match 82 & 83): shad Platt
Title of Legally Responsible Person must match 83b): Vice President
Name & Title. of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 980,214-1837
J%
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Sigr�aturep'F`�gally Responsible Person or Authorized Individual
I F/ ( �/?r I
ate
I P T TNOTE.
This form
must be signed by a responsible
corporate officer that owns
or operates the construction activity,
such as a president.,
secretary,
tr. o d . or vice president, or a
m ors age r- that is authorized
in acco rc n e with Pant IV, Section B,,
Item (6) of the NCG030000 permit.