NCC241993_NOI Signed Certification_20240702

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Brut this K e oorkplete scan and upload to the elvsltonk NQl
Met! Mail the original norm to the Ni 1,14 MLR Stoarnwwtater Program(with$t at)ctw k g pawing t+, chi*:w
at:
0ArW011 c1i 191irgy,Miiwlrsat&larks Rexwlucces S 01111Water Program
S 1: N. SelisborN Street,h•Ft o4 )Office tut0 )
let t:Main Service Center
Ra neigh,W.1+b99 1 f+1_
Oil FORM tOlt MAIL MUST PE CC MPt.ETtD WITH AN lltekilNAL StuNAIUHL (NO1 Otu,1l ai) I+k1 0 ti l..
Ate NC Grote at totwer 143,215.tS(,) 'InY"'raw who&Roo`ite y motes any fiche stotroare't repersvelecion, �v
. PFOICO Yoe to aft AetS,C06 k°! 'greet t+tt9Or^t t ax.ttlfrr 000sw4104 cx Mirbiiirt4 to*a ►lecula r.,«i ho% this
4rficie or a Mariit inteAtmeatin i t+AI?`A#*kr lid Cy a cuss 2 rieisdraseuiv'ai which mus, iieciewle a fine not to
wet*tart Jolters($-1CUk )1
Under penaltw ot law_I.,ertity Out(check ail boxes to indicate your agreement)
(3"am the person responsible for the construction activities ot this project, Mt satisfying the reguirements.lt this
permit,and to any rival or .rirrlinat penalties incurred due to v otattons of this permit.
Q The information submitted in this NO1 is.to the beat of im knowiedge and belief: true, accu ate,and complete
based on nay inquiry ot the person of persons who manage the s►•atcwwt, Of those persons directly responsible r i;
gathering the information.
O l will abide by all conditions of the awl the Amyx-wed t tiwsion anti sediment Control.
Plan.
El it the approved Erosion and Sediment Control Plan is not con pliant with wart It tMtoa^rnwaler Pothetion
Prevention Plan)of the , I will nonetheless a+nstere that all ocendititans of Part tI of the
permit are met on the project at alt times,
Q i hereby request cOvefeat under the and understand that coverage to den this
permit will constitute the permit requirements tot the titschar;;e)s)and is enforceable in the same nua-nnei as an
individual permit
1`role.1 Name(most matted*Al01• Cutbren, Divia on Lot I A
Specific Lot Numbers infest match Al tiLl 1 2
Pennittee(oust N►ii): Diamond Builders oft 111p' Mills INC
legally Responsible Person(must s.sttA sal a*J): NO. v Nelson
Toe of legally Ileapontible Perim(must motet LIN; Piildent
Print Name A Title of Signed If Auttteriaed
Individual plffeet Prom legally Responsible Person: Rioky Nstson Prstdent
Phone Number; 9104'3T•1 Se1
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Ii 'Sig atuI+{of legalt► Responsible Pelson of I;1,d hufiv+klual
• imopoarANTTN©TE; rim form Molt be►1aned hV a motpenstbte roL'i.'lttrtv Ohrr Ng W1711 t"++F+cSttrtrt the►tlrtstftfti+t78 0444+►t!r.
inch as a preirdent secrero+y, tfe+1luror Of Wer.metal/tilt, ur t+trtpmb)1f 1"t'"14(v4±e4 Ifs 6k."1/44 `f 040 r\.rrt !!', ,lei't'ku+a.
Item(6)of the Nf GOJt'all()permit