NCC230834_NOI Signed Certification_20230328

NCGQ1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NDI. b check) at:
Then, mail the original form to the NC Stormwater
Land Resaugraces iwr th $100ater check
mpaying y
Division of Energy, a
rogra
512 N. Salisbury Street, 6^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED A MPL� 21
THIS FORM YOU MAIL MU5T BE coMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 40
CFRPer NC 6eneral5tatute 143-225.60 (1), any person who knowingly makes any Jaise starerne nt, representation, or
certification in any applkation, retard, report pion, or other document filed of required to be maintained under this
Article or a rule imPlementing this Articfe ... shop he guJity of o Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars f$10,0001•
Under penalty of law, I certify that (check all boxes to indicate your agreement)
0 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.
QThe 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 NCG010oD0 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part Ii (Stormwater Pollution
Prevention Plan) of the NCGQ1000Q General Perm[ I will nonetheless ensure that all conditions of Part Ii of the
permit are met on the project at all times.
I 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 NC HWY 210 Townhomes (must match Ala): -
Specific Lot Numbers (must match Alb): 90
Permittee (must march 81); KDP Development, LLC
Legally Responsible Person {must match 82 & 831:
Phil Stephenson
Title of Legally Responsible Person (must match 83b):
Owner/Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number; 919-427-8654
6?r 03
Signature of Lega Resp sible Person or Authorized Individual Date
ft
• such
as a p rT ident This form �asurer,st be +gned by a responsible corporote officer that owns or operates the con5truction or vice president, or a manager that is authorized in acco da ce with Part JV, se tiJori B,
such as o presiderlL setlBrory,
Item (6) of the NCGol0000 permit.