NCC241004_NOI Signed Certification_20240404

NCGO1 Notice of Intent (N*N) 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 $120 check if paying by check)
at:
Division of Energy, Mineral /& Land Resources StonmvvaterProgram
Sl2N.Salisbury Street,6th Floor(Office 64OK)
1612 Mail Service Center
Raleigh, N[27699'1G12
THE FORM YOU MAIL MUST BE COMPLt'iD WITH.Al-A ORIGINAL SIGN�kTURE(NOT DIGITAL)[-**,CFR 122.227
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article. . .shall be guilty nfoClass 2 misdemeanor which may include m fine not bo
exceed ten thousand dollars($10,000).
Under penalty of law, | certify that(check all boxes to indicate your sgmeemnent):
[�) 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.
[�l 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.
C�
c� 1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
|�l If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
[v-,l I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
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 A2m): Bright Leaf- Phase I I
Specific Lot Numbers(must match Alb): 65-101
Pennittee(must match 81): Starlight Homes North CaFDliO@, LLC
Legally Responsible Person(must match 8J& 133): Raymond Rinker
Title of Legally Responsible Person(must match BJb\: Vice President of Land Development
Print Name/&Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person: L8WOeO Granger, [and Development Manager
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Phone Number: 919-616-5347
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SignatbI�« Legally Responsib|eP4ou2n-6r Authorized Individual Date
* /MPORT4NT8OTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such osopresident,secoeto/K treasurer,wr vice president, oro manager that is authorized/n accordance with Part IV,SertionO,
Item(6)4f the N[GO1O000permit.