NCC221568_NOI Signed Certification_20220421

NCG01 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 Wo check If paying by cheep et;
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6w Floor (Office 6409)
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 122,221
Per NC General Statute 143-21S.68 (i), any person who knowingly makes any false statement, representation, or
mTgf Won in any application, record, report, plan, or other document filed or required to be maintained under this
Art de or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may Include o fine not to
eaese+- , ten thousand dollars ($10,000).
under penalty of law, I certify that (check all boxes to indicate your agreement):
0 1 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.
Q 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
gaftwing the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
0 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 II of the
permit are met on the project at all times.
✓Q 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 -
Prom (mom match A,a). Laurel Ridge Lots 1, 10, 51
SpeofK Lot Numbers (must match Alb): 1, 10, 51
Permittee (must match ,)'Laurel Ridge Development, Inc.
wily Responsible Person (must match B2 & B3): Hadley Kirkland
Title of Legaiiy Responsible Person (must match 03b): Vice President
i ame &Title of Signed if Authorized individual
Dif iim from Legally Responsible Person:
O/Fff'dor"' 0,
WffAWA
Person or Authorized Individual
Biigl M m n* fwm ~be sJyrred by o reVonsffik corporate offker thot owns or berates the construction activity,
radr aor arptarsiale t� ssxars�ry, trsawrrp, oar trice prtsiiderrt, ore manager that is authorized in accordance with PartIV, Section B,
Ito" (67oftoEAsts iWWOWMk