NCC241573_NOI Signed Certification_20240522

NCGO1 Notice of Intent (NO1) Certification Form
Directions:
Print thi . 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 • Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 60 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST B COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.221
Per NC General Statute 143-215.6B ), any person who knowingly makes any false statement, representation, or
certification in any application, reco d, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this A tide . . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,00 r).
Under penalty of law, I certify that ( heck all boxes to indicate your agreement):
✓0 I am the person responsible or the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or c iminal penalties incurred due to violations of this permit.
❑✓ The information submitted i this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the erson or persons who manage the system, or those persons directly responsible for
gathering the information.
0 I will abide by all conditions ipf the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Erosion and ediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG 10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the proje t 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 Ala): Fhestnut Creek Lot 14
t
Specific Lot Numbers (must matci Alb): Lot 14
r
Permittee (must match B1): TheTuscan Group, Inc
Legally Responsible Person (must"match B2 & B3): Kirk T. Metty
i
Title of Legally Responsible Person (must match B3b): President
I
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 919. 35.207/
1
,i /i(r:.-°°% ,fir 5/21 /24
Signature of Legally R_ rsible Person or Authorized Individual Date
I
* IMPORTANT NOTE: This form must b signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized 9 in accordance with Part IV, Section B,
item (6) of the NCG010000 permit.