NCC230135_NOI Signed Certification_20230118

NCC01 Notices of Intent (N01) Certification Form
Dlrectlans;
Print thLsform,tamplate, scan arndupload to the alectrorii€ NQI-
Thenr mail the original form to the NC OEM LR Starmwa ter Program (with WO the€k if payimg by ctwck) at-
DiViSion in Energy, general & Land Resources Stormwater Program
512 N- Salisbury Street, &� Floor (Office {40K)
1612 Mall Service Center
Raleigh, NC Z 7699-1612
DSO NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE,
THE FORM YOU MAIL MUST SE COMPLETED WITH AN ORIGINAL SIGNATUFLE thDT DIGITAL) 140 CFR 1ZZ.ZZI
Per Art GerwrolSIMute 143,215.158 (i), omypegm Who krtowimgov M*ke5 arty fA5eS16temtiervt, represerttallorlr or
cernftcattarr in any aAatiraliarr, record, reporl, Part, or other dacumemt frAed or required to be maimtoined arider this
Article ar a rite implementing this Article - - -.Shalt be guilty of a Class 2 misdemeamar wkch may meckide o lum vial to
euceeef tern thousand d6lb rs f5;o oaQ�.
under penalty of law, I certify that jehedc all brnxm to irrdi a your ag€eerrr mr :
1 1 am the person respansl hie for the construrtlan a€tivlti e s of this pro]emt, for satIsfying the requirements of thk
permrtr and for any trial er trim Ina I penaWas I ncurred d ue to violations of thLs perm It
Q the information submitted in this Floc is, to the he-st of my knowBedge and beliefr truer accurate, and complete
Cased an my inqul ry of the person in r persons who manage [lie symiamr or those persons di r2ctly sespa rGi ble For
gathering the Information-
1 will abide by all condltlons of the NCGA iD15130 General Permit and the approved EroSlon and Sediment Control
Flan,
Q If the approved Eraslon and Sediment Control plan Is not oaminuant with Fart II IStormwater Pollution
Preventll!M Plan) of the NC603-OWO General Permit_ I will nonetheless ensure that all €o elitlansof Pan 17 of the
permit are met on the project at all ti mes-
r 1 hereby request coverage under the NCUO100OO General Permit and undatstand that c wage under this
perms will constitute th4 permit rKulrements for Lhe discharge(s) and Is en orceable In the same manner as an
individual permit.
ProjecL Name {Mu.St Match A]0): 8101 Holly springs road
tat Nurnbers imust malet?
Fermittee (mast mrrteh 81): St. Clair Construction group Ito
Legally Responsible Person (must match H2 & H31: Samuel St- Clair
Title of Legally Responsible Person imust match 93b): 0*1101'
fame & Titl2 bf Signed iFAuLhori.2ed Individual
Differs from Legally Responsible Person:
Phone Number: 919-559-071
111 W20
natu a of L esponslble Person or Autharizad Individual
Date
* IhAP0ffAN7h107f: Tins farm must be sjgrred by o responsible corporate direr tho towns ar aperales the cartstructian activity,
such as a president, secretory, treasurer, or vice president' or manager dhotis authorized in aerardaore with Part OV, Section $,
rtem (b) of the lu 60.1iZiM permfL