NCC214184_NOI Signed Certification_20210722

NCGO.'L Notio, af, Intent (NO'0 Certification Form
0reC`�-ionn:
Print this form, complete,scan and upload tn the electronic NOi
Then, mail the original fnnn to the NC DEMLR3tormwmter Program (with $1OO check if paying by check) at:
Division of Energy, K4\nero| 6k Land Resources Stormwater Program
512 N.Salisbury Street, 6* Floor(Office 648K)
1612 Mail Service Center
Raleigh, NC27699-1612
DO Nar RAML'IHXS FORKHO0PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACC���ED AS COMPLETE,
'THE FORN41 YOU MAIL MUS�r BE COMPLETED`V*mrH AN ORIGINAL
~^~~° SiGNP.Pal-URE(NOT~�` o) �!40 .22!
Per NCGeneral Statute 243-215.6B(i) any person who knowingly makes unyfalse statement, representation, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article uro rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars/$20,000.
Under penalty oflaw, | certify that(check all boxes to indicate your aBreemend:
D� 1 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.
O<� 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.
03 |will abide by all conditions ofthe and the approved Erosion and Sediment Control
Plan.
9 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe |will nonetheless ensure that all conditions of Part || ofthe
permit are met on the project at all times.
OX | hereby request coverage under the and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name f Project(must match Ala):
Magnolia Subdivisiorl
Specific
Legally b| | Entity(must match Bl): QC Development, LLC
- Legally Responsible Person (must match B2&B3): Scott Ouaintance
Title of Legally Responsible Person (must match B3b): President
Name&Title of Signed |f Authorized Individual
Differs from UResponsible
Sign�ture of Legally 1�(esponsible Person or Authorized Individual Date
° IMPORTA07NOTE. This form must 6osigned byo responsible corporate officer that owns oroperates the construction activity,
such oso president,secretary, treasurer, or vice president, o/o manager that is authorized hn accordance with Part IV,Section f,
/tem(6)oƒthe NCGO20D0Dpermit.