NCC220202_NOI Signed Certification_20220111

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
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, 6,r 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 122.22]
Per NC General Statute 143-215.6E (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):
Q 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.
0 The information submitted in this N01 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.
0 1 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 NCGO10000 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.
Project Name (must match Ala): Waxhaw Downtown Park
Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Town of Waxhaw, NC
Legally Responsible Person (must match 82 & B3): Jeffery Wells
Title of Legally Responsible Person (must match 83b): Town Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-843-2195, ext
Jeffrey Wells
1 /10/22
Signature of LegaJWXWsiblePerson or Authorized Individual 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.

AXVA
Permit Nu: date Submitted: 01I0712022
Residential Building Permit Application
Town of Waxhaw
1150 N. Broome Street
PO Box 617 Email: [e-mail]
Waxhaw, NC 28173 Fax: [phone]
704-843-2295 www.waxhaw.com
Contractor Name: Nxt Opp JP, LLC. Contact Nu:
Contractor Address: 12800 Thornburg Ct NC License Nu:
Contractor City/St/Zip: Monroe NC 28110 Email: L
Owner Name: Contact Nu:
Owner Address: •--
i r 1
Owner City/St/Zip: WAXhaw, NC 28173
Subdivision Name: Millbridge 7 Parcel Nu: 05165723
Street Address: , e'� �1� Lot Nu:
Nu. Stories: I Nu. Bedrooms SF:
Basement Heated SF: Basement Unheated SF:
11 Floor Heated SF: Garage SF:
2"d Floor Heated SF: Porches SF:
3'a Floor Heated SF: Decks SF:
Total Construction Cost: 4
1.
Project Description:
Applicant Name: Elizabeth Hamilton
Contact Nu: 7045344580
Applicant Address: 2800 Thornburg C:t
Email: [e-mail]
Applicant city/St/Zip: IMonroeNC28110
By signing the signature block below, I attest that I am an authorized agent for all parties concerned and that all submitted information, to
the best of knowledge and belief is correct. I further attest that the permit holder will comply with all applicable state and local laws, rules
and ordinances and that failure todo s)x7nay result in revocation of the permit and/or other actions as provided by law.
Signature Field Date:
Signature Field��—r`
By t 4:00 pm, Jan 07, 2022
Revised 02n712017