NCC230231_NOI Signed Certification_20230126

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI. a in b checks at:
Then mall the original form to the NC DLMLR Stormwater Program (mWith wat $10�check programp Y 9 Y
Divislon of Energy, Mineral & Land Resources Sto
512 N. Salisbury Street, 6th Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
ONIP
po NO
T MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLIcATION HAS BEEN ACCEPTE tj S C CFI 122 22]
THE FORM YOU (MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE N
Per NC General Statute 14.E 2I5.6B (i)
any person who knowingly makes anyfalse statement, representation, or
certification an PP o licattan, record, report, plan, or other document filed or required to aaln a tx fine noed under t to
Article or a rule implementing this Article ... shalt be guilty of a Class 2 misdemeanor which
may ln
exceed fen thousand dollars ($10,000).
Under penalty of law,
vnsible for the construction activities of this project,
0
E
I certify that (check all boxes to Indicate your agreement):
for satisfying the requirements of this
am the person rasp
permit, and for any civil or criminal penalties incurred due to Violations of this permit.
The information submitted in this NO[ Is, to the best of my knowledge and belief, true, accurate, and complete
based on ray inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
! will abide by all conditions of the �1CGt310DQ0 General e it and the approved Erasion and Sediment Control
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the KGO10000 General permit I will nonetheless ensure that all conditions of Part
permit are met on the project at all times.
11 of the
I hereby request coverage under the NQ D10000 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 permlt.
Project flame (must match Ala): Mehta Residence
Specific Lot Numbers (must match Alb)} Let 13 eddington Acres
Perrnittee (must mouth Bl): Peters CUStt}M Homes
Legally Responsible Person (must match 132 $ B3)-. Nicnoias r'eteFS
Title of Legally Responsible Person (must match 613b): Owner
Name & Tltle of Signed if Authorized I ndlvidual
Differs from Legally Responsible Person:
Phone Number: 704-264-4572
Signature of
risible Person or Authorized
1 I9123
Date
IMPORTANTNOTE., Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, .secretory, treasurer, or vice president, or a manager that is authorized In accordance with Port IV, {Section 0,
item (6) of the NCG010000 permit.