NCC243374_NOI Signed Certification_20241031

���K���� ����'�� �� U���K�� ��1) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $120 check if paying by check)
an
Division of Energy, Mineral & Land Resources 3tormwoterProgram
51ZN. Salisbury Street, 6`h Floor(Office 64UN)
1613 Mail Service Center
Raleigh, N[27699'1G1Z
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CPR 122.22]
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfolse statement, representation, or
certification in any application, record, report, plan, or other documentfiled 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 afine not to
exceed ten thousand dollars($1(l0O0).
Under penalty oflaw, | certify that(check all boxes to indicate your agreernent):
[�l | amthepeoon 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 NO| is,tothe 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.
[�
c� I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
|vl If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
[v� [ 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 A1o): McBaDe Subdivision
Specific Lot Numbers (must match A2b):
Permittee (must match 81): Ashton Raleigh Residential, LLC
Legally Responsible Person (must match 8Z& 83): Chris Hamrick
Tit|eofLega||yResponsib|ePerson (/nustmotch83b): \/iC8P[eSideDtCfFiDaOce
Print Name&Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 984-208-2254
� . � ~
Signature ofLe8aN�� Rexponoib|e Person or Authorized Individual ^ Date
* 0M9DRT4NTNQTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as op/esident,secretary, treasurer, or vice president, or manager that is authorized/n accordance with Part IV,Section B,
Item(6)oƒthe N[GO1O0O0permit.