NCC216851_NOI Signed Certification_20211210

NCGO1 Notice of Intent (N01) Certification Form
Ufrections:,
Print this farm, complete, scan and upload to the electronic NCI.
or
Then, maiI th e ori.gina{ fo rm to the N C D E M LR St o rmw a te r P rog ra m (wi th $ 100 check if payin g by check) at.
DI'vision of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street., 61rh Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN ACCEPTED AS COMPLETE.
THE FORM- YOU MAIL M UST BE COMPL ETED WITH AN t)RlGINAL SIGNATURE (NOT DIG ITAL) [40 CF R 12 2.22j
Per IBC Gene ral S ta tu te 143-21.5.6B (i),, any pers on who kn ow ingly makes any fafse staiQment, rep rexentativn, yr
certification its any application, record, repvrt, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article ...shall be guilty of Class 2 mrsdemeanor which may [nclude u fine not to
exceed ten tho usand dolla rs ($10, 000)*
Under penalty of law, I certify that {check all boxes to indicate your agreement),-.
Q I am the person
responsible for the
construction activities
of
this project, for satisfying the requirements of this
permit, and for
any civif or criminal
penalties incurred due
t4
violations of this permit.
The information submitted in this N01 is, to -the hest of rriy knowledge and belief, true, accurate, and complete
based are my'Inquiry of the person or persons who manage th.e system, or those persons directly responsible for
gathering. the information.
�] 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
I the approved Eros io n a nd Sediment Contro i Pion is not conipfiarlt vvith Part I (Stort-nwater POWIon
Prevention Plan) of the NCGOI 0 General Permit, 1 wi1l nonetheless ensure that ail conditions of Part It of the
permit are met on the project at all times.
0./ i hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same mariner as an
individual permit.
Project Name (must match Ala): Gardner -Lee Residence
Specific Lot Numbers (must match Alb):
er r (must match Bl): Gardner -Lee Pry erfi 11 L C
Legally Responsible Person (must match B2 & B3
); Luc
. Title of Lega It y Res po n s Ibi e Person (must mcrtch Bab):
Stokes soled A for Gardner -Lee P[qP:t�rh,-,.
��
Aaent for Gardner -Lee Prooerties 111. LLB
Name & Titleof Signedif Authorized Individual
Differs from Legally ibl Person:
�_e•J}��—.0 rr VIAA. _ • �.�,M �Mha-•IF' 7' 1'1.1r1 —�w
Phone Number: 919-730-8520
Gardner —Lee Properties III, LLC � �' 0% �4-+��
by Lucy Stokes, acting solely as agent*. t/'� CA' zo
02
Signatu re of Lega Ily Responsible Person or Autlfo"Fri'zed End 'dual� -- Date
IMPORTANT NOTE.,, This form must be signed by a responsible corporate officer Mat owns or operates the construction activity,
president,such as a ,, or vice president, or a manager that is authorized in accordance with Part / V, Sec tt"On Br
Item ) of the NCGO10000 permit.