NCC223810_NOI Signed Certification_20221114

NCG01 Notice of Intent (NOQ Certiftation Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (wfth $100 check I1PQYin9 by check) at
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street. 6- Pow (Office 640K)
1612 Mail Service Center
Raleigh. NC 27699-1612
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE-
TW KWM YOU MAIL MUST BE COMPLUM MRTti AN OIDGINAL 96NATURE (NOT MITAL) 110 CF* 12-221
Per NC General Statute 143-215 68 ril any Persian who knowingly makes any jam' statement or
certificatiOn in any Qppkvbcwk record; report pion. or other dmvment filed or required to be maintained wider this
Article or a ruk impkmenting this Article ... shall be gur7ty of a Cfoss 2 misdlrmearaor whkh rnoy kwk►de a fine not to
exceed ten thousand dollars ($1q,000J_
Under penalty of law, I certify that (dwck all boxes to indicate your agreementj.
0 I am the person responsible for the construction activities of this project. for satisfying the requ4ements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit_
E] 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.
i will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
[ j] If the approved Erosion and Sediment Control Plan is not compliant with Part t) ('Stormwater PoM lbw
Prevention Plan) of the NCG010000 General Permit. I will nonetheless ensure that aN conditions of Part N of the
permit are met on the project at all times -
El I hereby request coverage under the NCGO100O0 General Permit and understand that coverage under"
permit will constitute the permit requirements for the disctwrge(s) and is enforceable in the same rrnarrw as an
individual permit.
Project Name (must matchAla): lai1ey Meadow's Subdivision
Specific Lot Numbers(mustmatchAlb): i8
Permittee (must match 81): watt Development Corp.
L ally Responsible Person (must match 82 & 83): Ronald Watt
Title of Legally Responsible Person (mustmatch 83b): FireSWO7t _
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number 919-618-W46
�3�- &-&.-00�
Signature of Legally Responsible Person or Authorized Individual Dat!
* IMPORTANT NOTE: This form must be sngned by a respoi%M* corps ate of5cw thct L•wns or aptra/as the eo+— --c-1 I •ct vm
such as a pros►dent, secretary, heasurer, or vice present or a marager that ss outhaxicrrd A oecor+clanc+e oft PWt IV. 5at'hr
"m (6) of the NCG010000 permit