NCC191086_NOI Signed Certification_20190726

NCG01 Notice of Intent (NOI) Certification Form
Directions:
nt this form, complete, scan and upload to the electronic NOI.
mail the original form to the NC DEMLR Stormwater Program at:
sion of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6E (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 all boxes to indicate your agreement):
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.
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.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
�71 I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements forthe discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project:
Legally Responsible Organizational Entity: GL \u) ' C
* Legally Responsible Person: C
Title of Legally RespoAsible Person:
Signature:
ate: �' �6-
* IMPORTANT NOTE: 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 in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

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NAXNAAW
CERTIFICATE OF PLAN APPROVAL
The posting of this certificate certifies that an erosion and sedimentation control plan has been
approved for this project by the Town of Waxhaw Engineering Department - Sedimentation and
Erosion Control Division. This certificate must be posted at the primary entrance of the job site
before construction begins and until establishment of permanent groundcover as required by
the Town of Waxhaw Erosion and Sedimentation Control Ordinance.
Carringtonquare Parcel 2 SEC-015995-2019
Project Name and Location SEC Permit #
July 24, 2019
Date of Approval
Hours: Monday -Friday I& P. 704.843.2195
8:00 a.m. — 5:00 p.m. F. 704.843.2196
Christopher Rice
Sedimentation and Erosion
Control Division
P.O. Box 6
www.waxhaw.com
1150 North Broome St
Waxhaw, NC 28173