NCC224211_NOI Signed Certification_20221229

NCG01 Notice of Intent (NOIJ Cet•tification Form
Directions:
Print this formr complete, scan and upload to the elettronit NOk
Then, mail the origina I form to the NC DEMLR Stormwater Program {with SiGO check rf poyrng by check) at
Division of Energy, Mineral & Land Resourres Stormwate r Program
512 N- Salisbury Street, Ii Floor (Office E,401(}
1C 12 Mail Service Center
Raleigh, NC 27699-1612
00 NOT MAIL 7HI5 FORM OR PAYMENT LINTIL YOUR APPLICATLON HAS BEEN ACCEPTED AS COMPIETE-
1K FORM YOU Nt" MUST BE COMPLETED WITH AN ORIGINAL SIC, NATURE (NOT DIGrrAL)140 CFR 132.F21
PerNCGeneraJ Statute 143-215-6$ (r), onyperson who krrowrnglymokes crryforse storement, representatron, or
#i}1bNotian it) any oppricvtiogr record, report pion, orodrer document f0ed or required to be MWrrtoirwd under this
Arffde tEr o rtrlB rmp0&rnerttirtg this Article... shol0 be gutky of v Class 2 mrsdemeonor Which may include o fine nut to
exceed ton th umunddolirns $1QfiG0
Under penalty of law. I certify that (check all boxes to indicate your agreenwnt):
1 I am lfie person responsible for the construction activities of this project, foe satisfying the rer{uirement5 0l this
permit, and farany civil ar criminal penalties incurred due to violations of this permit_
Ij() The information submitted in this NOI is, to the hest of my knowledge and belief, trut•, accurate, and complete
b1sed an my inquiry of the person or persan5 who manage the systemr or those persons directly responsible for
gathering the information-
KI I wll I ahitie by all conditimng of the NCGO10OM General Permit and the approved Erosion a nd Se invert Control
Plan.
50 If the a pproved Erosion and Sediment Control Plan i6 not campGant With Part 11 {Swrrnwater Pollution
Prevention Plan} of the NCG010000 General PEFMlt, I will rrondheless ensure that ail conditigns a# Part II of the
permit are met on the p roject at all times-
KI I hereby request coverage unde r the NCGO 111000 GE ne ral Permit and understand that Coverage under this
permit wil I corestimte the perm it requirements for the disehargejs� and is enlorc able in the same ma nner aS ar5
individual permit.
Name of Praiect (must march Ala): Lot 30 Bella Vista
ScecificLatNumbers trnustmulch AYbl: Lt}t30
Legally Responsible Organizational! Entity (must murctr31}. St- Clair Construction Group
Legally Responsible Perso n {must match &2 & B3)= 5a muel 5t- CI a i r
Title of h egally Respo risible PPrsOn (mLnt mown 93h)= Owner
Name & Title of Signed if Author ixed Individual
Differs from l ega Ily Responsible Person_
Phone Number: 919-559-2071
9/25/2O22
Signature of ally ponsible Person or Authorized individual Date
mPVRTAMT oyu;rE- Tws form rnusf be signed byu resWsahk: €nrµorote ofIkET that owns of operates tine constnWdon actkrft ,
ouch as a president, secretory, treasurer, or one presAenf or a mnr+mger that d nuthormed Rn accordance with Part N, Sechon P,
Rem �bf of lice fsrCGPI0XV permit.