NCC191857_NOI Signed Certification_20190916

NCGO1 Notice of lintent (N,01) Clertification Form
F'riint this forirn, cornpint, scan and Iupfoad ter thiP ctlrlror"n6 INOL
Then imaH the ortigir-41 form to the NC DEMLR SWnnwaMr Mgmny,
ENAW of Energy, Mh wral & ILand Riesoii.irces Starnnwatieir Piriogra,. ini
512 N. Salisbury St�reet, 6111" Hooir
1632 IMaH ServiceSinter,
RalieigI'1, NC 2716919 1612
Fler NC,Genera/ Statute 143 215.6B i(i), arny,persian whc;rmilwinglyrnakes innyful-se sto tirmen it, representiatian,
orcentykadan W any apphcatfon, record, rigport, lon, i atherdooumientfito be rnaintoined
urider this Articife,or i im,plirmenting this Article . - - shall be guNify of a Class 2,irnisiderriwancir which i
Mc Mde a Ahe not to excef.:!,d ten thousanid Wars ($IQOOW,
Under penaly of kv, I ceNify that Mheck aH boXEn to odwe yow apommoji
At"; to peNon ruponvNe Nx the consvuctior acowtun of As Izrcjoc"" satisf"Iing
requirewumqs of his pen-na, and for any cmd or c; nonal pmiaitms inotwred due to Wavons of A,;
ir e 1, 11-1 9 t
zI i I e i In f o 1!, 1-11 '!i a 14":'j t i s u b Rr U u d 1 n LK S Pq 0 1 M, to the b l A a f n W k n MM r., d g o '-i t I 4,:] rltlr'a'fr rl "I i ECt C r:' 1. a r ""I ta r t"I 0
carnpiete baseiJ on 74"nq4,miry of We yKismi a; persons wK manipe 0 pc°rscrns
for g��Itf'.�Ipirrr�g the
;wH aNde by off conThons of Vhe]�gq4,PQQQ !�22g�t2� �£Inci the Erc1oorj
MOM Canto! Man
H the apprmvid Emsion and Wknent AM& Plan is riot contrAiant Ypth Pan H Qon=mer Poilubcirq
Pr`eVCjj-)tj1r')f"j
okke NCGO10D 0 Gcnm�z Per t i ejrr""'um that, zfflt of
Part H of to penril am rmq on Onquicoct at aH Wes
.Z I he eby Rmuest coverage under Are M�Qjggg'g Eg�t[n�t and undemand that cowyage under
WN Pemyt WH CMUMe he Pernrit requVernents fat the CfiS(Jrarg^ (SMild 15 irl the
saq""manner as an OndMal pennk
Narne of Ploject:
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Legally Respiornlb1e Oirgia6lziadonial II ii afty: ............ LIE ...............
Legally Re!-.-q:)oii rsiiblie Persion: �N' `-
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Ide ckeg �ly Resibrnsiit)iie Persai
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*1MPO,RTAN7"NO7'E,- rhifsfo,m7jj"?jLj.r ��tr be signed by a reslporrsible corqrwiaticj officer thiat mi or r.)I::wriates the
constructirm Ir,rctivity, Sud; as a gweaden; secretary, treasiurier, or vice president, or a manager �t'hat is
authorized in arr.:ciordanice with F"arti'V, Section 8, Itern (F) of the I'ViCGO10000 pierrWt
Far more tiqformiodon on siee,Pii W, Secti,r),n 13, Item (6) of the Nr-GiO.1.0000 pir!irmrt