NCC230695_NOI Signed Certification_20230320

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,1, Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT IVIAH- THIS f ORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH ANORIGINAL SIGNATURE (NOT DIGITAL) 140 rFR 1-;,22.22,j
Per NC General Statute 143-215.68 (i), any person who knowingly makes arty false statement, representation, or
certification in any application, record, report, plan,, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . . shall be guilty of a Class 2 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, tor satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan,
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part If of the
permit are met on the project at all times.
I hereby request coverage under the !NCGO19000-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
individualpermit.
-Project Name (must match Ala): Riverstone Estates Lot 8
Specific Lot Numbers (must match Alb): Lot 8
Permittee (must match Bl): Paragon Building Group, Inc.
Legally Responsible Person (must match 82 & B3): Joshua B. Mauney
Title of Legally Responsible Person (must match 83b): Owner
Name & Title of Signed if Authorized Individual
Differs from Leizaliv Resnon,6hip Pprcnw
91
Number:
of Legally
Individual
3-2-2023
Date
IMPORTANf NOTE. This form must be signed by OleSPOnsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice esident, or a manager that is authorized in accordance with Part tip Sections,
Item (6) of the NCG01 0000 permit.