HomeMy WebLinkAboutNCC230651_NOI Signed Certification_20230315NCG01 Notice of Intent (N09I Cer tfPfeadon Form
l
Prinnt this forrrs, Mcrpiee, ican end uPlrsad w the eLectronl[ M01.
Then, mail the origins[ fbrrn to the NC OEMLR Storrrlyrraser Pragyann [with S9 €he[kiJrayrpl,`ypflt�fpaq;
brviMon or E-'Irrgy, M•.npral& tans Itli.]urtci3+IgFFnWakBf Prtl$rarm
521 h 5Jisb'ury Sum, 6-Flam f(>FSre 5 OX)
3612 Mad 5er4lte Centcv
Raleigh, NC 27699-1$j,�
DO NOT M :'t THIS I nA M []A PAIME.4 r u NT L Y(3 JR APPtreaTi p;51 e r F ri r,CCEPUL) AS COMPLETE..
TVfE FMM V*U P"L MUST 9E C011AP ETED WrFJ4 AROMING19AL SI G HATUAE NOT MGMAQ [4U tFR 122_221
FirA1C a'erllfafSratrlre ]43=,�35.Gi# j7,� aryaersrxn wrarknpr4-00ymSXf: 0 ry!d"`mc 5rorfolem, repremnrerko, d£
rrfir,�4ifon iM any dAdeaffon, re pM rel tir7 p+Ort dr ofhN dricrxrL ^.:,'regwrgd #o be maMtvr ed trMdrr fhfs
ry-Cyr LirrrJe irnpkmenring rhd5 Arr+ c a .. shoe' bd 901Y aj o Vom 2 nisdrmemof KIWA may mcbdf o fine nW rn rr;Yli7..terr rhoG30rld d4Mv±s f�d'� a?Cr0%.
krr€!er Taerlahy 0f 18w, I €C'My that ¢che€k au boxn to lndirare your a�ee*ntntj;
21 ramtheperson FCSTOrsA4 for I[be oa+rstractkmactivite%4fth5ordjW,for W15f4ing1hereQulrmenuofthis
permit, and for any civil or tdrnirhal pBrlaflie; it curred du{ to viblslipng 0f this Nrm,-t.
d The fnfprmatlonaub07itag� In this Iff}d li, N the h15t of my km%Oedge and her nf, true, atwfote, arr0earnprrte
based on mp irsgruIry of jILE person or PCrwm vdia nuaaie the spsta n, ar those peflOnti 4irettry re SimnslUFe for
Ca h-rriq ct*informatl0n.
d 15'.+il abide by all cPnrflsions of the k
n. P rrrl artdaheappr0ved Ers#r0H Srnd $C�il15rn7p
plan_ ntrol
�✓ IflheapprnyaEfmian4rdSediment Qnwr lPJartisnot €ompGantwith Port n�5sormwaterPa@lUJ.Dn
Preventlan PJanMcif the fJ,CGt17d88L,Gene'ra1 Pen114 a 'kln0r►ethvIvs5 Cnsum Iha1 all condiriansof pSrt If of thr
permit or& met onihe pmlett at all tIMM.
I hereby reque5l covela rc under the N CGO10[RM6Genrral Rerrnit and understand that coveFdgr under this
Perrnit Will cpnstIcutrthfipt mit FiequirprnSntsfw'1hCdls€harge�sj and if Cnfor cable in the same wianncrw akn
ind-'.=fuEl p.ermlt.
f ra Nar1re sf mvrcy,.aPa : Thoma$ M. Denims & Rita M. 4enlon Rayocji je TfUSt AgrMNTMj
5�e€i!ft La*..r a, hers tnns? +porch AJ 6}:
M. D.enlori & Rita M. Derlton Rlq'1oca41e Trmt ftleem9nt
Ala Ptrson [muscrnotrh fj2 & &3b: Thomas M. & Rita M, Denton
.ry :N.tl€rn IL'PC71M mustms#eh_t&3b?:Owners -
Klrne & TitlCaf Signed iFAUthadied IndrAdual i i ~
2IFfers from LtZa Ily Responsible per+ion:
Pt*ntr4i:mb r. 252-671-7734
tirgnarurr=ofLeg.i`:ry4e?Panl:alePer „orAatFrOMxedindi'ndual '"- '�_
D e -
i s a +dr.nr,mnr. twr-'D err r� o roroerorya«retpro. orope+�rrsrr�rxorrsrrr�rtaanari ,y
yft i Y4 rhtNCGojoc ppeeft.Jr. p °�+Ihvtii aort'yWly rdia dreafowNr-Mb Port lv; 3rc.�,