NCC242114_NOI Signed Certification_20240715

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NCGO1 Notice intent ) 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 $100 check if paying by check) at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,6"Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAR MIS FORM OR PAYMENT UNTIL YOUR APPLICATION.HAS BEEN ACCEPTED AS COMPLETE.
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement,representation, or
certification in any application,record, report,plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
M 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.
Lcl 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.
IN I will abide by all conditions of the NC GO1.0000 General Per n t and the approved Erosion and Sediment Control
Plan.
IN If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Pollution
, I0000 gene:raa! Per it, I will nonetheless ensure that all conditions of Part II of the
Prevention Plan)of the i�CGt�.�.
permit are met on the project at all times.
N I hereby request coverage under the Nc il0000 General j?errnij 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.
Name of Project(must match Ala): Collier Gate Estates-Lots 6,7, 13, 14, 51, & 54
Specific Lot Numbers(must match Alb):Lots 6, 7, 13, 14, 51, 54
Legally Responsible Organizational Entity(must match B1): A&G Residential LLC
Legally Responsible Person(must match B2&B3): Jamie Godwin
Title of Legally Responsible Person (must match B3b): Member Manager
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 910-779-0229 EXT 104
Signature egally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be 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 in accordance with Part IV,Section 8,
item(6)of the NCG0.10000 permit.