NCC190054_NOI Signed Certification_20190417

'f IIIrectiI III""i
Print this form,complete,scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68(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 alli four boxes to 'indicate your agreernent):
C II am the person iresponsUe for the construction activities of this project,for satisfying the
requirements of thiis permit, and for any civil or criirniinall Ipenallties incurred due to violations of this
perrn iit.
ER The in-formation submitted in this NOII is,to the best of my knowledge and belief,true, accurate,and
compllete based on my inquiry of the person or persons who manage the system, or those persons
diirectiy respons'iblle for gathering the information.
[.2 l will)abide by all conditions of the Nt ( 0.1,0 ztu0� e rier ai Il�Iernriit and the approved IErosiiob and
Sediment Control) (Plan,
is if the approved Erosion and Sediment Control Plan is not compliant witlhn Part ill (Stormwater Pollution
Prevention Plan)of the INK'(3030130(')G(--iIEIZd fl f-41n111A,�, l willi nonetheless ensure that all conditions of
Part li of the perrniit are met on the project at all tirnes„
i:.... II hereby request coverage under the Q rle enf I'e r is t and understand that coverage under
Ns permit willl constitute the permit requirements for the discharge(s)and ii,s enforceable in the
sarne manner as an individual permit.
Legally Responsible Organizational Entrty:- µFitch Creations, Inc.
Legally Res onsibl P son:��, p , FItCh
/
Signature: �, � Date: .
*IMPORTANT NOTT . This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or price president,or a manager that is
authorized in accordance with Part IV,Section B., Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Dart IV,Section a, item(6)of the NCGO10000 permit.