NCC222627_NOI Signed Certification_20220725

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, Complete, scan and upload to the electronic Nil.
Then, mail the original form to the NC DEMUR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land resources Stormwater Program
512 N. Salisbury Street, 6Eh Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Do NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per !VC General Statute 143-215. 68 (1), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled 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 erne not to
exceed Ten Thousand dollars ($10,000).
Under penalty of law, I certify that check all boxes to indicate your agreement):
� i am the person responsible far the construction activities of this project, for satisfying the requirements of th-is
permit, and for any civil orcriminal penalties incurred due to violations of this permit.
� The information submitted in this NO] is, to the best of my knowledge and beliefs true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible far
gathering the information.
[A i will abide by all conditions of the NCG010000 Genera! Permit and the approved Erosion and Sediment Control
Plan.
X If the approved erasion and Sediment Control Phan is not compliant with Part !I (Stormwater Pollution
Prevention Plan} of the NCGQ10000 General hermit I will nonetheless ensure that all conditions of Part I[ of the
hermit are met on the project at all times.
hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the d isch a rge(s) a nd is enforcEable En the same manner as an
individual permit.
Name of Project {must match A.1rx}: Cherry Tree Place
Specific Lot Numbers must mach Alb): N/A
Legally Responsible Organizational entity (must match B1): AS Land Development, LLC
Legally Responsible Person (must match B2 & 83): Steven Shuttleworth
Tine of Legally Responsible Person must mach 133b): Managing Manager
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Nurnber.
SKiK.'
Signature of Legally Responsible person or Authorised Individual
-l3-zz
Date
* IMPORTANT NOTE:
This form
m u t be signed by a responsible
corporate officer th at owns
or operates the construction activity,
such as o r.r,
secretary,
treasurer or vice president,, or a
manager t at i at prized
ire accordance with Part I V ,� ��
Item (6) of the IVCGQ30000 permit.