NCC221579_NOI Signed Certification_20220504

NCGO1 Notice ofIntent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NO|.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources StormnwaterProgram
512N.Salisbury Street, 5*Floor (Office 64OK)
1612Mail Service Center
Raleigh, NC27699'1612
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 122.22]
Per N[GeneralStatute 143-215.6B (i), any person who knowingly makes.anyfalse statement, representation, or
certification in any application, record, report, plan, orother docurnentfled or required to be maintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$2(lDDU/.
Under penalty oflaw, | certify that (check all boxes toindicate your :
[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.
The information submitted inthis NO|is, tothe best ofnyknowledge 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.
| will abide byall conditions ufthe NCGO10000 General Permit and the approved Erosion and Sediment Control
[�| If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions ofPart Uofthe
permit are met on the project at all times.
[Jq | hereby request coverage under the NCGO10000 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): FearrngtonK8illcrOft Realignment
Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Fitch Creations, Inc.
Legally Responsible Person (must match B2 & B3): Greg Fitch
Title of Legally Responsible Person (must match B3b): Vice President
Name & Title ufSigned if Authorized Individual
Differs from Legally Responsible Person:
Phone Number. 919 542 4000
,I
Signature'dfLena
iblaiiemonorAuthorized Individual
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such asopresident, secretary, treasurer, mvice president, momanager that is authorized in accordance with Part IV, Section B,