NCC221932_NOI Signed Certification_20220520

Directions.
Print this form, complete, scan and upload to the electronic NOI.
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 Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6B (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 a 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 penalty of law, I certify that (check all bomes 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.
0✓ 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 II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part it of the
permit are met on the project at all times.
Q I 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): Jaggers 1067 Western Blvd
ific Lot Numbers (must match Alb): 1
Permittee (must match B1): Capital Construction and Contracting LLC
Legally Responsible Person (must match B2 & B3): Allen Willis
Title of Legally Responsible Person (must match B3b): Allen Willis
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-398-4904
Signature of Lega`(ly Responsible Person or Authorized Individual
5111 2022.
Date
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 permit.

5369
CAPITAL CONSTRUCTION & CONTRACTING, LLC
PH. 919-398-4904
P.O.BOX 17884 PINNACLE
RALEIGH, NC 27619 87-863/640 -12
05/17/2022
0
N
N
PAY TO THE **100.00
ORDER OF NC DEMLR Stormwater Program
One hundred and 00/100** **� * ** ** * ** ***** * ********* ******* * *** * *****�**�*** **�*�* � ***** ** DOLLARS a
NC DEMLR Stormwater Program
512 Salisbury St. a 8 8
6th Floor (Office 640K)
Raleigh, NC 27699-1612 L
MEMO AUTHORIZED SIGNATURE
Jaggers 1067 Western Blvd Jacksonville, NC ,—_
1100000536911' 1:06400563?1: 110iB0010503[=1311'
CAPITAL CONSTRUCTION & CONTRACTING, LLC
05/17/2022 NC DEMLR Stormwater Program
Stormwater permit for NC
Pinnacle Checking (6008)
Jaggers 1067 Western Blvd. - Jacksonville, NC
CAPITAL CONSTRUCTION & CONTRACTING, LLC
05/17/2022 NC DEMLR Stormwater Program
Stormwater permit for NC
Pinnacle Checking (6008)
Jaggers 1067 Western Blvd. - Jacksonville, NC
5369
100.00
100.00
5369
100.00
100.00
')DELUXE CORP- 1,800-328-0304 www.deluxeforms.com 5581064/03-16 ,+
8834729500
BF10131 STKDK05 06/25/2019 15:49 -133-