NCC220256_NOI Signed Certification_20220118

NCGO1 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 � 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 143-215.68 (i), any person who knowingly makes ony folse statement, representation, or
certification in any application, record, report, plop, or ocher documentfiled or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of o Class 2 misdemeanor which may include o 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.
❑✓ 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.
✓❑ I will abide by all conditions of the NCG010000 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 �► of the
permit are met on the project at all times.
[_✓_] I hereby request coverage under the NCG010000 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.
. Northwest Thorn Bluff
Specific Lot Numbers (must match Alb): N/A
Per-mittee (mist rxwtch B1): Northway Hornes.LLC
Legally Responsible Person (must match B2 & 83): Cyrus Mojdehi
Title of_Legally Res_ponsible Pelson (mus-tmatch-B3b4:-Manager
Name &Title of Signed if Authorized Individual N/A
Differs from Legally Responsible Person:
Phone Number: 858-354-1479
1/10/22
Signature of Legally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This form muse be signed by a responsible corporate officer that owns or operates the construction activity,
such as o president, secretory, treasurer,, or vice president, or o manager that is authorized in accordance with Port IV, Section B,
Item (6) of the NCG010000 permit.