NCC241581_NOI Signed Certification_20240523

NCGO1 Notice of Intent ( NOI ) 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 Stormwater Program
912 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. 68 (i), any person who knowingly makes any false statement, representation, or
certification inany application, report,' record, plan, or other document filed or required to be maintained under this
ruleimplementingthis Article . . . shall be guiltyofa Class 2 misdemeanor which may include a fine not to
Article or a
exceed ten thousand dollars ($10, 000).
Under penalty of law, I certify that (check all boxes to indicate your agreement)
ro�ect
✓ 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.
0The
information submitted in this NOI is, to the best of my knowledge g and belief, true, accurate . and complete�rectl responsible for
based on my inquiry of the person or pers
ons who manage the system, or those persons directly
gathering the information. Sediment Control
0 I will abide by all conditions of the
NCG010000 General Permit and the approved Erosion and
Plan.
t comp liant with Part II (Stormwater Pollution
approved Erosion and Sediment Control Plan is no p tall conditions of Part II of the
0 If the pp General Permit I will nonetheless ensure that Prevention Plan) of the NCG010000 -
permit are met on the project at all times. this
Permit and understand that coverage
� I hereby reque
st coverage under the NCG010000 General under in the same manner as an
permit will constitute the permit require
ments for the discharge(s) and is enforceable
individual permit.
Project Name (must match Ala): 1508 Barony Lake Way
Specific Lot Numbers
(must match Alb): Barony Lot 6
Permittee
(must match 81): Yasir Syed
Legally Responsible Person (must match
82 & 83): Yasir Syed
Title of Legally Responsible Person (must match B3b): Owner, GC
Print Name & Title of Signed if Authorized Owner
Legally Responsible Person: Yasir Syed,
Individual Differs from g Y p
Phone Number: (919)2259869
5/20/24
nature of Legally Respon
e Perso or Authorized Individual Date
* IMPORTANT NOTE; This form must be signed by a responsible corporate officer that owes or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCG010000 permit,