NCC224143_NOI Signed Certification_20221219

NCC01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR 5tormwater Program (with $100 check if paying by check) at,
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
❑O NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122,221
Per NC General Statute 143-215,68 (i), any person who knowingly makes airy false stotement, 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 o Class 2 misdemeutror 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):
✓[] I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
✓ 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 far
gathering the information-
1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan► is not compliant with Part II {5tormwater Pollution
Prevention Plan) of the NCG.410000 General Permit. I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
r❑ I hereby request coverage ender the NCG010000 General Permit 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 (mast match Al a): Pearl Street Townhomes
Specific Lot Numbers (m us t match A I b):
Permittee (mustrnatch 81): 153 Capital, LLC_
Kevin .Jones
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b): Officer, Secretary of 153 Capital, LLC
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
704-640-0518
Phone Number:
12/0612022
ally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This form must be signed by ariesponsible corporate officer that owns Dr operates the construction activity,
such a5 apresident, secretary, trea5urer, or vice president, or manager Char is outhori2ed in accordance with Part N, Section 8,
Item (6) of the NC6010"permit.