HomeMy WebLinkAboutNCC220864_NOI Signed Certification_20220223NCGO1 Notice of Intent (N41) Certification Form
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ONision of (narp, IVinerai 6 tand Mww[+s Stamswit/r Peorsm
$12 N. Sa igbwY Street, f l Ftoor 1OW9 r 64%)
1612 ltrail Sew" Cgmtf
Raleigh. NC 17691-11W
DO NOT MAIL THIS FORM OR PAY101NT UNTU YOUR APPUCATIDM HAS "th At Cf PIID AS COVPtt TV
TW FVRM YOU MAR MUST SE COFifKMD VRTW AN OR$ MilAt Wt"TURt (NOT DoGTAs) 140 CFR 122-Ul
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t.kceed era 0%*A sddo*rs (3IQ0w)
l rder Penany of tare, I CM?fY tr•,t ui*utt of tows to inacate your averment l:
0 I am the person reWe sibie fors the 0Qr4U', [1k>n Wtrifles of tNa ptOWI, Iw ""Styeg the re" oe tt+ts
permit, and &W arry (MI oe co, ^e as pen4M41 oXW'ed &0 to vlptatians Co tha Pwrit
Q The r.Aon &taw s,rte-.tied in thn NOI Is. to IhP best of my tr4w4rd9! and be}.et True, *cc ara*, and Corr Plette
based on r,Y1f rryritV of the Perw", Of gemDns Ktfd maNQe the SyLtein, or IhQse Puns drre[T1y eeip4rrtrW }M
lathered the hfoern&Tion.
Q r will abide ay f1 condAbns or V+t �rtPral it a Sr and Tine kA;wv ed tiresron ar`d SrtJ we+t ContrdT
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Prevveniort Plana of Ihar NCGdl{+�74Ses�i
Permit are rret on the Peo^t at as simes-
r❑ I [sere" request twrer4w ur4er the �rrgia0oa G_enrral QYr!R i ar d "efstarrd iho cowaFe Un6rr WS
Perm it"oon&IItem the W-ml tea uirtmtmfor the drscnargPls'i and 11,enfcere4blc In the same manner &tan
individual perm t.
prDkct Name ,n;,fimotrhAla :
Heritage Pointo - Lot 35
SwAlc Lot Numbers (meat march +t2_ 6}�
Peirri"te (must r wCh 811: V114H TAN
tr s: Ref n Uble t�rrson P%usr emfch 62 & 93)-
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OWNER
tda Re e u
Nafrle 6 Title of Sagntd df Authorized Indiv,dutl VINH TAN
DRfers from Leib sicW. rtsibir PeKO
Phone Wunder. 9193296789 —
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S#mture of LePly Resararvtle PerSPn orAu':hceired in&Odal
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