NCC190561_NOI Signed Certification_20190610

NCGO1 Notice of Intent (NOI) Certification Form
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, 6 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68(i), any person who knowingly makes anyfalse statement, representation,
or certification inany application, record, report, plan, wrother 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 o fine not bn exceed ten thousand dollars/$1(IDO{V.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
7- 1 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.
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m 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.
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|will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
c� if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG{18 | will nonetheless ensure that all conditions of
Part || of the permit are met on the project ai all times.
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^� | hereby request coverage under the NC"GO' and undeotondthat coverage under
this permit vvi||constitute the permit requirementsfor the discharQe(s) and is enforceable inthe
same manner asan individual permit.
Name VfProject: Courtyard Cary
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Responsible Person: Manager
Signature: Date: 6
* /&YPOR7AyVTNOTE. 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/n accordance with Port IV, Section B' Item (6)u/the NDG010O0Dpermit.
For more information on signatory requirements, see Part IV, Section B, Item (6)of the NCGO10000 permit.