NCC243344_NOI Signed Certification_20241031

0dCGO1 Notice mfIntent Certification F0rtm
Directions:
Print this form, complete, scan and upload to the electronic NCI.
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 StommvvaterProgram
512N. Salisbury Street,6m Floor(Office 64OK)
1G12 Mail Service Center
Raleigh, N[ 27699'1612
THE FORM YOU MAIL MUST BE[O 'PLETED -,O[H AKJORIGINAL SIGNATURE (NOT DIGITAL) '48CFR %22'22l
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfulse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article oro rule implementing this Article. . . shall be guilty ofo Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars/$1(lDDU1.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[71 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.
[�l 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.
| will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
|,71 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
F71 I hereby request coverage under the NCGO10000 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 Alo>: Subdivision for CMH Homes Hwy. 210 Garland, NC
Specific Lot Numbers (must match/41b):
Pernmittee (must match 81):'(�k��� Homes, Inc.
� �
Legally Responsibl-e Person (must match 83& 83): Nathan Britt
Title ofLegally Responsible Person (must match 83b): Assistant Secretary
Print Name Q'Title of Signed ifAuthorized
Individual Differs fron� Legally Responsible Person:
�
Phone Number: 865-380-3000
Signature of Legally Responsible Person or Authorized Individual Date
~ IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or cperates the construction activity,
such osopresident, sxcretoqK treasurer, o,vice president, oro manager that is authorized/n accordance with Part IV,Section B,
Item(6)o/the N[GO10000permit.