NCC221912_NOI Signed Certification_20220519

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71'
NCGO . 1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NDI.
Then, mail the original form to the NC DEMLR 5tormwater Program {with $100 check r'f paying by check} at:
Division of Energy, Mines! &Land Resources Storrrtwater Program
57.2 N. Salisbury Street, 5th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27599-161.2
DO NET MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC Genera! Statute 143-215.66 (i),, any person who knowingly makes any false statement, representation, or
certification in ar�y application, record, report, plan, nr other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty ova Class 2 misdemeanor which may include afin e not to
exceed ten thousand dollars ($10,000).
Under enalty of law, 1 certify that(check all faxes to indicate your agreement):
1 am the person responsible far 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 NCI 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 these persons directly responsible for
gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
�' if the approved erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
revention Plan} of the NCG010000 General Permit, I will nonetheless ensure that all conditions of dart jl of tine
ermit are met on the project at ail times.
hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
hermit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
niamp of Prnipct (mUSt tnatCh Ala): Harvest View Estates
';r,Prif,r. 1 nt Numbers (must match ATb):
Lawrence Homes, Inc.
I o����►� Rprr�nnsihle Organizational Entity {must match Bl}. _
I opaflv RQsnonsible Person (must match B2 8c B3); Jeanette Langer
_TC.�r- F
Title of Legally Responsible Person (must march Bib):
Name & Title of Signed if Authorized Individual
Differs from legally Responsible Person:
Phone
umber-.
19.57x8".77V7
Vice President
r� Signature f 4F R pansible person o A oriz4d tndiWidual
NOTE:� r st be signed b a recorporate
iffcer that owns or op crates theconstructionactivity,
such as a preslident, se't4etary, treasurer,, or vtce president, or a manager that is authorized in accordance with Part J
item (6) of the NCG010000permft.