NCC221194_NOI Signed Certification_20220328

NCG.01 Notice of Intent (N01) Certificati6on Form
Directions,
Print this form, complete, scan and upload to the electronic N01.
Then, mat( the original for to the NC DEM LR Stor water Program (with 100 check if paying by check) at
IF
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Sall'
sbury Street, 6th Floor (Office 640K)
1612 Maid Service Center
Raleigh, NC 27699001612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETES
THE FARM YOU MAIL MUST F3E COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 222w221
Per NC General Statute 143-m215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application,, record, report, plan, or other documentfiled or required to be ma
Article or a rule implementing this Article .. , shall be guilty of a Class 2 misdemeanor which may
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
intat"ned under this
include a fine not t 0
Ltl ! am the person responsible for the construction actl*vities of this project,, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this hermit.
EV]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
RVf
a
poi
gathering the information.
! will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Se
dimen't Control
Plan.
If the approved Eros0
ion and Sediment Control Plan i's not compliant with Part II (Stor water Pollution
Prevention Plan) of the NCG010000 General Permit, t will nonetheless ensure that all conditions 01,11111111 Part II 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.
Project Name (must match Ala). Peltier Point
Specific Lot Numbers (must matrh AIb):
Pe 1"ttee (must match BI) w
N/A
Bell Investment Group, LLC
ally Responsible Person (must match 82 & B3)..a Thomas F. Bell
Tale of Legally Responsible Person (must match 83b)•
Name & Title of Signed if Authorized Individual
Dif' from Le-alFy Responsible Person:
Phone.Nu ber.* 919-584-6247
-.WON"
Manager/Me ber
e of Legally ResponsiF�le Person or Authorized Indiv!I---- Now-
idual
Date
* IMPORTANT NOTE: Thisform must be signed by a responsible corporate o%fiter ttiat awns or operates the construction activity,
such os a president, secletary, treasurer, or vice president, or cr rnonager that is au�harized in accordance with Part IV, Section g,
Item (6) of the NCGO10�000 permi
t.