NCC217187_NOI Signed Certification_20220104

NCG01 Notice of Intent (NOp rertifiratimm Pnrm
Directions:
Print this form, complete, scan and upload to the electronic NO!.
Then, mail the original form to the NC DCMLR 5tormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salishury Street, 6- Floor (Office 640K)
1612 Mail Service Center
Raleigh, SIC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
Per NC General Statute 143-215.6B N, any person who knowingly makes any false statement, representation, or
certification in any application, record, report pion, or other document filed or required to be maintained under this
Article or a rule implementiny this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars 1$10 000J_
Under penalty of law, I Certify that (check ail boxes to indicate your agreement):
0 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.
Q 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.
MV 1 will abide by all conditions of the IVCGQlgorx7 G�nQrai Pnrmit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pallution
Prevention Plan) of the NCGQ10000 General Permit I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
Q I hereby request coverage under the id CGOI000Q General Permit and understand that coverage under this
permit wiiI constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Project Name (must match Al.): O'ConnelI Farms. Lot Nos. 5-8
Specific Lot Numbers (must match Alb):
Permittee (must match BI): O'Connell Developing, LLC
Legally Responsible Person (must march 82 & 63): Brian O'Connell
Title of Regally Responsible Person (must match B3b):
Member/Manager
Name & Title of Signed if Authorized Individual Brian O'Connell
Differs from Legally Responsible Person- -
Phone Number: 919-291-3794
Briars O'Connell 12l2-2121
Signature of Legally Respo il,le Person or Authorized Individual Date
IMPORTANT NOTE: This farm must be signed by a responsible corporate officer that owns or operates the ronsttuctlon Octivity,
such as a president, secretary, treasurer, or vice president, or o monager that is authorized in accordance with Para 1V, Section B,
item (6) of the NCGO10" permit.