NCC216307_NOI Signed Certification_20211118

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC OEMLR 5torrnwater Program (with $100 check if paying by check) at:
Di0sion of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street. 61, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL TH15 FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122,221
Per NC General .Statute 143-215. 68 (f), oily person who knowingly makes any false soternent, represer;tutlon, or
certifocatfort M any application, record, reMrpfarr, or other document filed or required to be maintained ander this
Article or a rule implementing this Article - , , shall be g0ty of a Class 2 misdemeanor which may irlcluWe a f orle not to
exceed ten thousand dollars ($10,000),
U nder penalty of law, f Certify drat (check all boxes to Jndicate your agreern ant):
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
Permit, and for any civil or criminal penalties incurred due to violations of this permit.
IN The information submitted in this Nol is, to the best of my knowledge and belief, true, accurate, and Complete
based on my inquiry of the person or persons who ma nage the system, or those persons directly responsible for
gathering the information.
I will abidn by all conditions of the NCG010040 General Perm it a nd the approved Erosion a nd Sediment Control
Plan.
Jf the approved Erosion and Sediment Control Plan is not compliant with Bart 11 (5tormwater Pollution
Prevention Plan) of the NCG010000 General Permit, f wilt nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times -
I$ J hereby request Coverage u nder the NCGO10000 General Permit and understand that coverage under this
permit will constitute the Permit requirements for the discharge(s) and is enforceable in the sarne manner a5 an
individual permit -
Name of Project (must match Ala): Village Gate
Specific Lot Nurn bers (muss matchA1b); 2 & 3
Legally Responsible Organizational Errtity (mug match B-0-MlIa a Gate at Kn ig htdale, LLI; & Smithfield PUD, LL
Legally Responsible Person (mustmatch 62 & 83): Kenyon Burnham
Title of Legally Responsible Person (must match B3b); Managing McJmber
Name & Title of 51grped if Authorized Individual
Differs front tegaIlly Responsible Person: /A
Phone Number: 5 5-465-0099
Signature of Legally Responsible Person orAuthorized Individual
191011
Date
IMPORTANT NOTE., This form must be signed by a responsible corporate officer that owns or operates the construEtiorl activity,
such os a president, Secretary, treasurer, or vice president, bra manager [hat is authorized in accordance with Part tV, Section 8,
Item (6) of the NC6-01pOpermit.