NCC232901_NOI Signed Certification_20230927

NCGO1 Notice of Intent (NOI) Certification Form
Arections:
Print this form compete,scan and upload to t►+e eiectronk NOI.
Then, marl the original form to the NC DEMUR Stornnwater Program(with$100 check /poyling by Owe!)at.
Division of Enemy, Msreral&Land Resources Stornmrwater Program
S12 N Salisbury Street.6' boor(Office 640R)
1612 Mast Service Center
Raleigh,NC 27699-1612
CO NOT MA■l TH5'tORM OR PAYMENT UNTIL YOUR APPLKAT)OM NAS SEEN ACCEPTED AS COMPUTE.
THE room you MAIL MUST K COMOU T't0 WIIN AN OAISMAL I*11NE NOT 01111/Ati peon IUa
Pee Pk Cie en*Statute 143-225 6d(1).ony person who knowingly mokei Derr foist statement, rcprefento!.ort or
serf ficotoa+in ony op bcotron, record,report pion. or other document filled o✓rewired to be rnoiato.ned under tfrs
Arndt o+o dale Nrlplenterrdnp tAo ArtKk shod be guilty of o Coss 2 nwsderneencv*hrc,moy include o foie not to
exceed ten tAousond donors(S10,000)
• Under penalty of law,I certify that(check as boats to indicate your agreement)
El I am the person responsrb►e for the construction activities of this project.for satisfying the requirements of this
permit and for any airs or crtetwnat penalbps Incv•red due to violations of this permit
Er The rnformatson subm.tted vi tM NOI rs.to the best of my knowledge and belief,true,accurult.,and complete
based on my inquiry of the person or persons who manage the system.or those persons directly responsible for
gathering the information.
[r I w Ill abide by all concmons of the NCCs41Q000 4eneral Perini and the approred Erosion and Sedrnent Control
Plan
El If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Polkiton
Prevention Plan)of the NCG01OOQ0 General Permit, I will n en theless ensure that ad conditions of Part II of t
wind are met on the project at all tines.
Er1 hereby request coverage udder the NKG41400O General Perin and understand that coverage under this
permit will constitute the permit requirements for the dsschargt(s)and is enforceable M the%arse rnar,ner a%an
rndridual permit
Pro)ect Name(must match AI o; Maple Spftflgs Estates• Lot 19
Specific Lot Numbers(must match Alb): _
Peewrttee(must match 81): Ashley Cobbs
hEj1y Resoonsibl.Person(mast match 82 i 8J) Ashley Cobbs •
Me of Levity Responsible Person(must retatch 83b1 O hror
Print Name a Title of Signed rf Authorized
lndzindua Differs from(natty Responsible Person: N/A
Phone Number. 919-519.4246
Srdr►at Of Logan,'Respontrbla Person or Authorized Ir+aMaw+ 4,2a543
Date
• MMpRTAM NOTI Thls form must tie&Veto:by o respor+sibie tap: ore officer Mot owns or operates the construction activity,
such os a president, secretory, treasarcr, or we pits dtrit, or o monger tAot n ovt►+orved An accordance with Part 114 Section S.
Rein(6)of the 11I00020000 permit