NCC200161_NOI Signed Certification_20200115

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,
complete, scan and upload tot
ie electronic
NOL
en, mail the original form to the
NC DEMLR Stormwater Program
with
00 check if paying by check) at:
Division of En
y, Mineral & Land Resources St
rmw
er Program
5122z.
Salisbury Street, W4 Floor (Offi
a 64010
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FOR
OR PAYMENT UNTIL YO
R A
PLICATION HAS BEEN
REVIEWED
AND ACCEPTED AS C
MP
ETE
' General Statute 143-215.68 (1, any person who knowingly ma s any false statement, representation,
ification in any application, re ord, report, plan, or other docum nt file d or required to be maintained
this Article or a rule implemen$ing this Article ... shall be guilty of a Cle iss 2 misdemeanor which may
a fine not to exceed ten thou. and dollars ($10,000).
Uc
er penalty of law, I certify that (c
eck all boxes to indicate your ag
eeme
t):
I am the person responsible
for the construction activities of
his project,
for satisfying the
requirements of this permit,
and for any civil or criminal peni
Ities i
curred due to violations of this
permit.
The information submitted
n this NOI is, to the best of my kr
owled
a and belief, true, accurate, and
complete based on my inquiry
of the person or persons who
'nanag2
the system, or those persons
directly responsible for gatt
ering the information.
I will abide by all conditions
of the NCG010000 General Perm
t and 1he
approved Erosion and
Sediment Control Plan.
If the approved Erosion and
Sediment Control Plan is not compliant
with Part 11 (Stormwater Pollution
Prevention Plan) of the NC
010000 General Permit I will norietheless
ensure that all conditions of
Part II of the permit are me
on the project at all times.
I hereby request coverage t
nder the NCGO10000 General Pe
mit and
understand that coverage under
this permit will constitute the
permit requirements for the di
charg
(s) and is enforceable in the
same manner as an individual
permit.
e of Project: Lassiter Ridge
L
g Ily Responsible Organizational E
tity: Darryl Evans Develo
ent, LLC
L
g Ily Responsible Person: Da
Evans
I of Legally Responsible Person: Manager
*
i nature: �...�
*
nt Name and Title of Signed if Authorized
rlividual
Differs from Permittee: /zz1&- , J- GaBv /
f "
G 4
P
ne Number: 919-934-3884
* RTANT NOTE: This farm must be signed by a responsible corporcfe off r that owns or operates the
c truction activity, such as a president, secretary, treasurer, or vice reside t, or a manager that is
a tJ iorized in accordance with Part IV, Section 6, Item (6) of the N( 10000 permit.
P ore information on signatory requirements, see Part IV, Section B Item (6) of the NCG010000 permit.