NCC205702_NOI Signed Certification_20201215

Notice Intent Certification Form
Print this form, complete, scan and upload to the electronic N01.
Thert, rraail the original forma to the NC DEMLR 5tornwlater Nograrta (With $101) cheek if ,dying byclaeck) at, -
Division of Energy, Mineral & Land Resources 5tnrmwater Program
512 N. Sallsbury Street, 6:r, 6loof (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MML T41S FORM OR PAYMENTUNTIL YOUR APPLICAVON. HAS BEEN
Per NC (teneral Statute .1 d3-2.15,60 (i), tiny Person who knowingly make s any false stotertten t representarinn,
Of cett►ficatiort in orry opplicution, record, rePOff, Pkn, Or othef dvctamerrt filed or required to be rtlohitained
under this Article or a rude implementing this Arria:le - .. shall be guilty of a class .2 misdemeanor tvhich may
Include o fine riot to exceed ten thousond dollars ($10,0()0),
Urtcser pel'alty of raw. t certify that {che(k all byes to inditite your agroesnew):
I aria the person responsible for the consteuctron activities of this project, for sati .lying, the
requirements of this permit, and far any civH or criminal penalties incurred due to violations of this
gar+raaait,
XI the- Ireformation submitted in thls NOI is, to the best of my knowledge ind belief, true, accurcte, jncl
complete based on my inquiry rf tht- person or prsmn.s who manage the. system, or throw rer5nos
directly respons1t3le fof gatheriaag the Inforrraatioll,
I will abldee by all ctiaactitlons of the NCG0 W,)) G=r nr as lIerwflflt and the oppruyed Efosiora arld
sedirne.nt Control Phn. --..._
X if the approveed Erosion and Sediment Control Plat) is not compliant with (Tart lI (5tormwatcr vollutlon
Prevention Plan) of the NCGOWQXa ra, rnenif P& - t, I will nonetheless ensure that all ronditions of
Part 11 of the permit are met casa the project at all tines.
t hereby reque5t cover ago (it)der the ria < r� r� E �:t G n a 1 R try and taraele:ilond that cove(apc- ruck+r
this permit will ronstitute, the pa'rntlt requirements for the dischargels) and is enforreablo in the
same rnaanner as an Individual permit,
Marne of Project: C"Oas(al _Villas Subdivi�u>lf,.�___..--
Legally Resparasible Ctrpanlraclonal Entity. Nags Head Construction & De-velol)[1101l, I13E.
Legally Responsible. Person: AIfretl Norman
Title of Legally Responsible Person., V iCC Preside[it
fete; l L -/' -
Print fume and Ttle of Signed if Authorized
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Phone NornberT 7S _7�' 5.2 .-5p f �x-
IMPORMNr NOTE. This for►n must he signed by o responsible corporate officer, that o►vns or operates tine
ronstroCtiort activity, such as u President, secreinry, treasurer, Or vice president, or a manoyer that as
ourhorized in accordance with Port IV, Section B. item (6) of the NCG010000 perrn': r.
roc more infofwatiun OR slynotory requirements, see Prat IV, Seetion 6, Item (6) of fire NCG010000permit.