NCC223841_NOI Signed Certification_20221121

NCG01. Notice of Intent (NOI) Certification Farm
Directions:
Print this form, complete, scan and upload to the electronic N01.
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, Go- Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL. THIS FORM OR PAYMENT UNTIL YOUR APPLICAnON HAS BEEN ACCEPTED As COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE. (NOT DlGf fAL) (40 C;FR 1.22.221
Per NC Genero! 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 boxes to indicate your agreement):
0 i <tni the person responsible for the construction activities of this project, for satisfying they requirerfi'ients of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
d The inforniaVon srihmitted in this NCI is, to the bust of my knowledge 311d belief, trUe, accurate, EWA complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
B I will abide by all conditions of the NCG{):.f00J[7_t e rtic: ral Permit and the -.ippr-ov(,d Frosion and Sediment Control
Plan.
[) If the approved Eros}on and Sediment Control Plan is n{at compliant with Part II (Stormwater Pollution
Prevention Plan) of the NC6010.000 General Permit, # will none=thelessensure, that ail conditions of Part II of the
perrnit Ire met on the project at all times.
d 1 hereby request coverage under the NCG010000 Ge rter,ai (�c�rntit aiad Understand that coverage under this
permit will constitute the Permit requirements for the discharges) and is enforceable in lien ;ame manner as an
individual permit.
Name of Project (must match Ala): HEWITT WOODS Ph1
Specific Lot Numbers (must match Alb): 7
Legally Responsible Organizational Entity (must match Bl): POWHATAN PARTNERS, LLC
Legally Responsible Person (must match 82 & 133): NATHAN EVANS
Title of Legally Responsible Person (must match B3b): MANAGING MEMBER
Name & Tit#e of Signed if Authorized Individual N/A
Differs from Legally Responsible Person:
Phone Number: 919-345-6729
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Signature of Legally Wesponsible 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 B,
Item (6) of the NCG010000 permit.