NCC221177_NOI Signed Certification_20220401

NCCOI Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N0L
Then, marl the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 Floor (Office 640k)
1612 Mail Service Center
Raleigh, NC 27699-1612
170 NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS £SEEN ACCEPTED A$ COMPLETE
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
Per NC General Statute 143-215.68 (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 o 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 penaity of law, I certify that (check all boxes to Indicate your agreement)
�✓ 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 NOI 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 NCG010fx10 General Permit and the approved Erosion and Sediment Control
Platt,
[]✓ if the approved Erosion and Sediment Control Plan is not compliant with Part 11(Stormwater Pollution
Prevention Plan) of the NC0010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
�✓ I hereby request coverage under the NCG93.0000 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.
Name (must match Ala): Lots @ Delling Downs
Specific Lot Numbers (must match Alb): 6 & 7
Permittee (must match 81): Dellinger Builders LLC
Legally Responsible Person {must match 82 & 83): Cammie Dellinger BUrns
Title of Legally Responsible Person (must match 83b). 0 W V1 pr
Name & Title of Signed If Authorized individual
Differs from Legally Responsible Person
Phone Number- 7049028483 - -
1
L _ 01riL L YL L e1� Qi �. S �. s .oil _ 3116120
Signature of Legally FiesponsibP Person or Authorized individual Date
° IMpoRTANT NOTE: This form must be signed by a responsible corporate uf]icer that owns or operates thr construction activity,
such as a president, secretary, treasurer, at vice president, or a wa« ager that is outharied in accordon(e with Ran iv, serriorr 8,
item 46) of the NCG010" permit,