NCC222884_NOI Signed Certification_20220811

INC O otice of Intent (NOI) Certification Fora
Directions.,
Print this form eomplete, scan and upload to the eleetroniC Ndl:
Then, mail the original form .to the. NC.DEMLR Stormwater Program {with $104 check if paying by. check} at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N.-Salisbury Street; 6LI, Floor {:office 640IC)
1612 Mai€ Seryice .Center
Raleigh, NC 27699-1612.
DO N07 MAIL TFIIS FORM € R PAYMENT
UNTIL YOUR.APPUCATION HAS.13EEN RE9dIEWED AND ACCEPTER AS COMPLETE .
Per NC General Statute.143 215.6E..(i); any person tuh0 knowingly makes any false statement, representation; or
certification in any dppiicatiari, record,.report,. plan, or other docamerit.filed or required to be maintained under this
Article 6r a rule implementing this Article.:: '. shall'be guilty of p Class 2 misdemeanor which may include o fine not to:
exceed ten thouscrrid,da!lars ($201000).
Under pena€t.y'of law; l .certify that (check all b®xes to iridicate.your agreement):
r .1'am the person responsible for the constructiiin activities of this.preject; .for satisfying the requirements of this
permit, and
:-fa rany.dvil or. ddrn€nal penalties incurred dwe to violations of this permit.
::.The information subm tteci €n this N01 is; to the best of my knowledge and be.11ef; true, accurate, and complete
based on my inquiry of the person or persons.who manage the system, o.r those persons directly responsible for
gathering the. information.
I tivill abide by all conditions of the NC Q100Q0.General P.errnitand file approved Erosion arid.Sedirnerit: Control
Plan: -
>� If the approved Erosion. and Sediment Control Plan is not Compliant with Part II (Stormwater Pollution
Prevention Plan) of the. N_CCQIQ_p]o General Perm t, I tvlll nonetheless ensure that all conditions of Part II of the . .
permit are met an the project at all times.
1 hereby request coverage under the NCG010000 General Permit and understand that coverage .under.this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Name a#Pro ject (must rnatrh`A3a):
Olivet Subdivision
Specific Lot Numbers (mustmatch.0.lh}:
Legally Responsible Organizational Entity (must match 61); 011vet3$ LLC - —
Legally Responsible Person (rriu.st matcFr k3� & 33}; .James E. Ailed, Jr.Title of.Legally Responsible Person (mu.s match 83b}: MembeC
Name &.Title of Signed if Authorized Individual
Differs from. Legally Responsible Person
------------
Phone Number. .919.201..7480 ---
7-1 _.. _
Signatur of Legal y Responsible Person or Authorized Individual - -Date
* 1MPORTANTNOTE. 1-his form must be signed.by a responsible corporate Officer that Owns ar operates the construction activity, .
such as a president, secretary, treasurer, or vice president, ❑r a manager that is uuthoriaed ih accordance with Part !V, Section 6,
Item (6) of the NCG010000 permit.