NCC231024_NOI Signed Certification_20230414

NCGO1 Notice of intent (NO9) 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, 60, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
ION HAS BEEN ACCEPTED AS
LETE.
DO NOT MAIL THIS FORMOR PAYMENT UNTIL YOUR OOMPLETED WITH AN ORIGINALIS SIGNATURE(NOT DIGITAL) [400C RP122.22J
THE FORM YOU MAIL MUST SEC
Per NC General Statute 143-215.68(i), any person who knowingly makes any 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):
l°` ► 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.
j 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.
the approved `;,:� Sediment(-e��irC!
0 will abide by all conditions of the NCG010000 General Permit and aa1p; Erosion .
Plan.
(('�'j Ifthe approvedErosion and Sediment Control Plan is not compliant with Part ii (Stormwater LJ I r conditions "_
Prevention Plan) of the NCG010000 General Permit, ! will nonetheless ensure that all conditions of Par II of the
permit are met on the project at all times.
.I, -����"rills
I request coverage under the NCG010000 General Permit and understand that coverageunder� hereby ��-`-j'permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala) D -03 .
Specific Lot Numbers (must match Alb): 39- ---
�toal finders homes
Permittee (must match B1):�
Leslie Groves
Legally Responsible Person (must match B2 & B3): — �,� — —�---
Title of Legally Responsible Person (must match B3b): 'D\V\Sion Ioye,sida, l _ __--
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person: —Y_f—_-- — —
Pho Number: 9'10-486-4864 -----
r 3I13 a3
`, � _- ---- -- Date
Signature of Legally esponsible Person or Authorizecl Individual
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Port IV, Section B,
Item (6) of the NCG010000 permit.