NCC223666_NOI Signed Certification_20221102

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, 6t^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (i), any person who knowingly makes any folse 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 ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
✓Q I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civif or criminal penalties incurred due to violations of this permit.
Fv—J The information submitted in this Npl is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
✓[� I will abide by all conditions of the
Plan.
and the approved Erosion and Sediment Control
[✓ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the , I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
�✓ I hereby request coverage under the
and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): The Reserve at Satterfield Farm
Specific Lot Numbers (must match Alb):
Permittee (must match B1): Williams Builders of Rocky Mount, LLC
Legally Responsible Person (must match B2 & B3): David Williams
Title of Legally Responsible Person (must match B3b): Member Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: NIA
Phone Number: 252-977-7991 ZS'Z —Z�' 4$�
Sign ure of Legally Responsible Person or Authorized Individual
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 6,
Item f6) of the NCGO10000 permit.