NCC223903_NOI Signed Certification_20221129

Directions:
Print this form, complete, scan and upload bothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources 6tonnwaterProgram
512N.Salisbury Street, 6thFloor (Office 64UK\
1612Mail Service Center
Per NCGeneral Statute 143-215.GB01any person who knowingly makes anyfalsestatement, representation, or
certification in any application, record, report, plan, orother documentfled or required to be maintained under this
Article nrorule implementing this Article ... shall be guilty qfoClass 2misdemeanor which may include ofine not to
exceed ten thousand dollars ($1D,UOO).
Under penalty oflaw, Icertify that (check all boxes toindicate your agreennent):
El |amthe person responsible for the construction activities ofthis project, for satisfying the nequiementsmfthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
EI The information submitted |nthis NO|is, tuthe best ofmyknowledge 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.
Cl | will abide bvall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
El If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart Hufthe
permit are met onthe project atall times.
E3 | hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discha/Qe(s)and isenforceable inthe same manner asan
individual permit,
Name of Project (must match Ala): Abby Meadows
Legally
Specific Lot Numbers (must match Alb):
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Legallyb| Nathan Evans
Titleof Legally ResponsibleManaging M800b8F
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Num�er�g19-345-6729
- ° ^`
ure—df LefgalLv-R—esponsible Person or Authorized Individual
*IMPORTANTNOTE: This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such ozopresident, secretary, treasurer, orvice president, oromanager that isauthorized hnaccordance with Part IV, Section 8,