NCC233571_NOI Signed Certification_20231205

NCGO1 Notice of Intent(NOI)Certification Form
Directions
Print this form.complete.scan add upload to the electronic NOt.
Then,marl the original form to the NC D(MLA Stormwater Program(with Silo check rf paying by check)
at
Division of Energy,Mineral i land Resources Stormwater Program
St)N Salisbury Street.6^Floor Office Most
1612 Mal Service Center
Raleigh NC 276994612
T)e FONM YOU MAIL tNNST at COMPUTIDWITN AN 0Nt6RlIIOpATU par oseITAL)iao CPI 122.22)
Per NC General Statute 143.21S 6A(i).a y person who knowingly makes any/one statement,representation,or
certification M any appkcation.record,report,plat or other document filed or required to be momtorned under this
Arbdf or 0 Mit O pYsMttep tAn Mx* .shoe be guilty of a Class I misdemeanor which may include a fine not to
exceed ten thousand dbNrs(310.040)
Under penalty of law.I certify that(check al bona to indicate your agreement)
I am the person responsible for the construct,On activities of this protect,for satisfying the requirements of Ole
permit•and for any cm]or criminal penalties incurred Clue to violations of this permit
Q The information submitted a,this NOI is.to the best of my knowledge and bekef,true,accurate,and cornpMkt
baud on my inquiry of the person or persons who manage the system.or those persons directly responsible for
gathering the information
l I win abide by all conditions of the NCGQ10000 General permit and the approved Erosion and Sediment Contra,
Plan
0 If the approved Erosion and Sediment Control Plan is not compliant with Pan n(Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit I well nonetheless ensure that all conditions of Part a of the
permit are met on the protect at a0 times
r0 I hereby request coverage under the NCGO10000 General Prrmit and understand that coverage under this
permit wnN constitute the permit requirements for the discharges)and is enforceable M the same manner as an
individual permit
Protect Name(must march Ala):The reserve at falls lake ph 4
Specific tot Numbers(must match Alb!: 77
Permrttee(must march 81)-St Clair Construction Group tic
Legacy Responsible Person(must match 87 i 83): Samuel St Clair li
Title of Legally Responsible Person(must moth 83b).Owner
Print Name b Title of Signed if Authorized
Individual Men from Legally Responsible Person:
Plane Number 919.559.2071
,�—nrt A-1 h 2/3/2023
Signature of Legally Responsible or Authorized Individual Date
• IR(FDRTANT NOTE Phis form mud be Pined by o responsible corporate officer Mot own or operates the construction actrvm
turn as o president.tecrrtory,trewtww,or we prrs+Ornl,u a rnanoipB that is aYMbr&ed it accordance with Port IV,Section fl
Item 161 of the MC6010000 permit