NCC241077_NOI Signed Certification_20240410

NCGO1 Notice of Intent (NOI) Certification Form
Directions: �
Print this form,complete scan and upload tothe electronic NO|.
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 StormwaterProgem �
512 N.Salisbury Street,6m Floor(Office 640K) �
1612 Mail Service Center �
Raleigh, NC27G99'1612 �
THE,FORIVI YOUJM IL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGO 40 CIFR 122.22]
PerN[GeneodS&otute143`Z25.68(i), onypenmnwhoknowing/y/nokesonyfbbestoten/ent,/eoosentudon, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this �
Article oro rule implementing this Article. . .shall be guilty ofoClass 2 misdemeanor which may include o fine not to �
�
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement): �
�
[v-1 I am the person responsible for the construction activities of this project,for satisfying the requirements ofthis �
permit, and for any civil or criminal penalties incurred due to violations of this permit.
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.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Fie-1 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.
[�| 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 A1o): The Barony Lot 14
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Specific Lot Numbers(must match A2b): Lot14
Permittee (must match B2): Mangum Design Build, Inc
Legally Responsible Person(must match B3& 83): Christopher Mangum
Title of Legally Responsible Person (must match 83b): President �
Print Name&Title of Signed ifAuthorized �
Individual Responsible Person:
Phone Number: 919-422-2126
of Legally Responsible Person or Authorized Individual Date
~ 0kPORIANrNOTE: Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such oso president,seoetaM treasurer,o/vice president, oro manager that is authorized/n accordance with Part IV,SrctionB,
Item(6)of the NC6O20000permit.