NCC230725_NOI Signed Certification_20230329

NCGO1 Notice of Intent (NO[) Certification Form
Directions:
complete, scan and upload to the electronicN Ok if paying by check) at:
print this form, comp ram [With 5100
Then, mail the original form to the NC �Me al & Land Resources Stormwater Program
Division of Energy, Street, 6� Floor' (Oftice 640K)
51z N. SaIi5burY
1617 Mail Service Center
Raleigh, NC 27549-1612
HAS BEEN ACCEPTEO AS ❑O NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APGIFIA TI ON GNA RE (NET DIGITAL) 4QO PI S
THE FORM YOU MAIL MUST BE COMPLETED WITH AN false statement, representation, or
Per NC General 5tatute �43-2IS.ec r , rePany rt, plan,
who then docu makes any
Certification in any appficatian, record, report p
tan, or other dacurrrent filed or required to be maintained under this
his Article ...shoo be guilty of a Class 2 misdemeanor which may include a fine noto
Article or o rule Implementing t
exceed ten thousand dpNors (.530,000)
Under penalty ❑f law, 1 certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this lut fl1ns tvf this pe satisfying
the requirements of this
m
❑ ro
permit, and for any civil or criminal penalties incurred due to
The information submitted in this NOI is, to the best of my thesystem, ge oa thosebelief
pe persons directly true, accurate, resp° complete
etfor
based on my inquiry of the person or persons who manage
gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and sediment Plan is not compliant with Part 11 (Stormwater Pollution
• I will nonetheless ensure that a!1 conditions of Part Il of the
Prevention Plan) of the NCG010000 General Permit
permit are met on the pro;ect at all times.
Q I hereby request coverage under the NCGolo00d General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the satire manner as an
individual permit.
Project Name (must match Ala): Deliverance Church
Specific Lot Numbers (must match Alb)_
8752-03-32-2844
Permittee (must match BT), Carolina Cornmerciai Contractors, LLC
Legally Responsible Person (must match B2 & B3). ❑ebbie McNeil -Smith
Title of Legally Responsible Person (must match 83b):
Name & Title of Signed if Authorized individual
Differs from Legally Responsible Person:
Phone Number: 919-673-3134
Church Administrator
Signature of Legally Responsible Person or Authorized Individual Date
IMPORTANT NOTE- This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president. secretarv. treasurer_ or vice aresident. or a manager that is authorized in accordance with Part IV. Section B.