NCC191619_NOI Signed Certification_20190830

NCGO1 Not�ice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnvvaterProgram
S12N.Salisbury Street, GmFloor
161ZMail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, orother dommentfiled or required to be maintained
under this Article ororule implementing this Article ... shall beguilty ufoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars /$2(lU00/.
Underpenalty oflaw, |certiff ythat (check all boxes toindicate you ra8veennent):
|amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or chminal penalties incurred due to violations of this
permit.
IX 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.
C2 |vvi|Uabide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
X If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe |vviUnonethe|es ensuvet6ata!|cond�iunsof
Part ||mfthe permit are met onthe project atall times.
RI | hereby request coverage under the NCGO11.0000 Eieneral Pernnitr and understand that coverage under
this permit wiUconstitute the permit requivementsfortheJischarQe(s)and isenforceable inthe
same manner asanindividual permit,
Legally Responsible Organizational Entity: Caviness Land Development, Inc.
* Legally Responsible Person:
Title of Legally Respon son: Qwne-r/lVl;;naqP-r
Signature:
ate: 08/27/2019
*
IMPORTANTNOTE: This form must besigned byoresponsible corporate officer that owns oroperates the
construction activity, such osopresident, secnsto/Xtreosurer,orvicepmsident,oromonogerthotb
authorized /naccordance with Part IV, Section 8,Item (6)ofthe N[G020000permit.
For more information onsignatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.