NCC230688_NOI Signed Certification_20230315

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NQI.
Then., mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by checks at:
Division of Energy., Mineral & hand Resource5 Stormwater Program
512 N. Salisbury Street, 6,1 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT
MAIL
THIS
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 122.22]
Per 11lC General Statute 143-215.68 (i), any per -son who knowingly makes arryfafse statement, representation,, or
certification in any appJrcatran, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article .. _shall be guilty of a Class Z misdemeanor 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 phis Na! is, to the best of my knowledge and belief, true, accurate, and complete
based on any inquiry of the person or persons who manage the system, or tease persons directly responsible for
gathering the information..
0 I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erasion and Sediment Control Plan is not compliant with Pert II (Storrnwater Pollution
Prevention Plan) of the NCGO10004.Genera! Permit, i will nonetheless ensure that all conditions of Part It of the
permit are met an the project at all times.
� 1 hereby request coverage under 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 (must mdtch Ada): De Cesare
Specific Lot Numbers (must match Alb).41 D7
Permittee (must match Bl).- Oscar Koehler Jr Koehler Homes Inap
Legally Responsible Person (must march 82 & I33): Oscar Koehler J r Koehler Homey Inc
Title of Legally Responsible Person (must match 83b): President
Name &Title of Signed if Authorised Individual
Differs from Legally Responsible Person:
Phone Number: 704-309-0227—J
n
Signature of Legally Responsi
Peron or -Authorized Individual
3/9/20
Date
IMPORTANTNOTE.- This form must be signed�hla responsible corporate officer that owns or operates the construction activity,
such as o president, secretary, treasurer, or nice president, or p manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG01 0000 permit.