NCC231481_NOI Signed Certification_20230516

NCGO1 Notice of Intent (NOv) 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, Floor(Office 640i<)
1612 Mail Service Center
Raleigh, NC 27699-1612
S
DO NOT MAIL THIS FORM ORBE PAYMENT UNTIL H AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 1 2.221
ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED
Per NC Genera!Stature 143-215.56(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($10,000).
of (check al: boxes to indicate your gre'eisers ):
Under nen,alt,, law, I ce"trig that (check
Q i am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
QThe information submitted in this COI is,to the best of my knowledge end belief, true, accurate: and Compete
based on my inquiry of the person or persons who manage the system, or those persons directly respoisible Fps
gathering the information
�;� ��;_ _-- ,�� Erosion --�d `cull-,,,:�;,_Cn,-::�"c'
(� I abide el' ccr,d:_ic..s the NCG010000 General Permit a - -, - E
Plan
on and sediment Control Plan is not cco,'1'•iriiarr with Pert II (;•tormwa`ef �.1:.....,
(� li The d!�Fr:�`!_ Ef�JS•�n � a c•� �} +�all rf}!1(,1ri'�?r,S of Je. . II O
Permit, I will n•_r,ettr_I ss l r° ^a•
,:,._;e;,;, --, a;��i ,,r+�e NCG010000 General
permit are met on tne project at ail times.
de the NCG010000 General Permit any c sta-d that coaeras_
-" l' )a•�{is$
f.'+ter:QeoID in the same ITt3i�:12r as Ail
individualreo'Jirer:entj or the discharge(s
permit will C�7nsiiiUic the, G
Jividual -
inUl�:'i'J�_lai Ve-MIiT. aa
Project Name (must.match Ala): CGLYV I V\ - 001
Specific Lot Numoers (must match A:1b): — -
r'...I.I I,_Ice (must match
Dream finders names , -c, - -- - -
'- _- Leslie Graves
Legally Responsible Person (must match 82 & B3)_ _-- -- - — -- - - - -
-ode of Legally Responsible Person (must match B3b): vIVIS►Oln loye,sidert
Name &Title or Signed if Authorized Individual
Differs `rom Legally Responsible Person: --.. -
Pho Number: "10_'86_46 4_ — ... - -
S{11; — - _ - _i Signature of Legally esponsible Person or Authorized Individual Date
• � orn�e officer t.nnr owns or�_per•ai�s the-anstru�hon ocrrvr[;:.
" IMPORTANT NOTE: This form must be signed by a responsible core- .
such.ns o president, secretory, treasurer, or vial president, or manage' that is aurhonzed it occorrdnn,ce with Pert IV. section B
item (C)of the N( 0i'0000 Gen rr' t