NCC220291_NOI Signed Certification_20220126

Directions
Print this form, complete, scan and
i mail the original
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upload to the electronic N01,
form to the NC DEMLR Stormwater Program with $140 check if paying by check
Divis8ion of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Seryice Center
Raleigh, NC 27699ftR 1612
NOT lViA{L THISTHIS FORiORi �PAY11/IENT UNTIL Y0U1?;1"%PPL1CA ION 11AS BEAN ACCEPTED. As COMPLE
haRM YOU NIl ft IL BE COMPLETED WITH AN ORIGI
NAL SIGNATURE (NO�r DIGI ALI I�o
Feral Statute 143-215.66 (iJ, any person who knowingly makes any false statemen representation,
n in any application, record, report, plan, or other document filed or required to e maintained un E
i
rule Implementing this ArtCle ... shall e guilty of a Glass 2 misdemeanorw 1cl may include a fine
thousand dollars ($1 �, 000).
alty of law, (certify that check alb boxes to indicate your agreement):
in person responsible for the construction activities o is project, for satisfying the re uiremei
emit, and for any civil or criminal penalties incurred due to violations of this permit.
information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and c
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>ed on my inquiry of the person or persons who manage the system, or those persons directly respc
tier411 ing the information.
III abide y ai ionsor
of the �1CG010000 General Kermit and the approved Erosion and e imer
n 6
e approved Erosion and Sediment Control Plan is not compliant with Paormwa er li Pollution
�vention Plan) of the NCGO10000 General Perni'lt.0-04-oh-- %m-, I will nonetheless ensure that all conditions of Pay
�mit are met on the project a t al ! times.
�reby request coverage under the N�G01U�00 Genere ra, m ! and understand that coverage under
hmit will constitute the permit requirements for the discharges) and is enforceable in the same ma
Ivi ual permit.
ame (must match a : Hampton Woods
Lot Numbers mustmatch
�e (must match :am on Woods Residential, LLC
responsible Person must match B2 & B3}: Chris Boone
'_egally stble Person must match B3b): Manager
. iteof Sig ed if Authorized n ivi ua
rom e a es onsi e Person:
lumber:
signature
Responsible Person or Authorized Individual
i 1a
Da
NT NOTE: Th 's
president, sec
rm must be signed by a responsible corporate officer that owns or operates the constructi*or
t ry, treasurer, or vice president, or a manager that is authorized in accordance with Par
t 1V, t