NCC243415_NOI Signed Certification_20241104

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI. !n bycheck)
Then,mall the original form to the NC DEMLR Stormwater Program (with S120 check if pay g
Division of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,64N Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOUR MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.22]
Per NC General Statulte 143-215.6E(1),any person who knowingiy makes any false statement,1epresentation, or
certification in any application,record,report plan,or other document fiVed or required to be maintoined under this
Article or a rule implementing this Article...shall be guilty of a Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars(S10,000).
Under penalty of IbW, I certify that(check all boxes to indicate your agreement):
E✓ I am the person responsible for the construction activities of this protect, for satisfying the requirements of this
permit,and Tor any civil or criminal penalties incurred due to violations of this permit.
E✓ The informa Lion submitted in this NOI is,to the best of my knowledge and belief, true, accurate,and complete
based on mat inquiry of the person or persons who manage the.system,or those persons directly responsible for
gathering the information.
✓� I will abide by all conditions of the NOG010000 General Permit and the approved Erosion and Sediment Control
Plan.
E✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
E✓ I hereby request coverage under the NCG010000 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
Indh^ldual permit.
Project Name(must match Ala): Governors Club— Lot 606
Specific Lot Numbers(must match Alb): LOT 606
Pcrmitteo(must match 81):John and Martha Reilly
Legally Responstlble Person(must motch B2&B3): John and Martha Reilly
Title of Legally(Responsible Person(must.motch B3b):'Owner
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Nu r: 8 4452850
11/1/24
/ Signature Legally Responsible Person or Aut. zed Individual Date
• IMPORTANT NOTE: This form must be signed byo responsibk corporate officer that owns or operates the canstrucction octRity,
such os o president,secretory, &coverer,or vice president• or o manor r Motis outhorir ed In accordance► ith Port AV,Section B,
Item(6)of the NCGOl0000 permit.