NCC241349_NOI Signed Certification_20240503

CGO1 Notice of Intent ( NOI ) Certification Form
Directions:
' tint this form, complete, scan and upload to the electronic NOI .
Then, mail the origi al form to the NC DEMLR Stormwater Program (with $ 120 check if paying by check)
at:
l ivision of Energy, Mineral & Land Resources Stormwater Program
512 N . Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143 215. 6B (i), any person who knowingly makes any false statement, representation, or
certification in any applicat . n, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementi g this Article . . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollar. ($10,000).
Under penalty of law, I cert fy that (check all boxes to indicate your agreement) :
0 I am the person res • onsible 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.
0 The information su mitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquir. of the person or persons who manage the system, or those persons directly responsible for
gathering the infor , ation.
N I will abide by all c• nditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
gi If the approved Er• • ion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) o the NCG010000 General Permit, I will nonetheless ensure that all conditions cf Part II of the
permit are met on he project at all times.
0 I hereby request c• erage under the NCG010000 General Permit and understand that coverage nder this
permit will constit to the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must m • ch Ala) : Club Road Lot A
Specific Lot Numbers ( ust match Alb): A
Permittee (must match : 1 ): Lisa Burford
z
Legally Responsible Person (must match B2 & B3) : Lisa Burford
Title of Legally Respons ble Person (must match B3b): Owner
Print Name & Title of Si 3ned if Authorized
Individual Differs from egally Responsible Person :
PhoneNumber: 330- 85-6000
, ), ,!:-Au t_ ,(,) 1 5/1 /24
Signature of Leg Ily Resin ible Person or Authorized Individual Date
* IMPORTANT NOTE: This f rm must be signed by a responsible corporate officer that owns or operates the cons action activity,
such as a president, secret y, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 ermit.