NCC220143_NOI Signed Certification_20220120

'M
AN
NCGO1 Notice of Intent (N01) certification Form
Directions.
Print this form, complete, scan and upload to the electronic N01..
mail the original form to the NC DEMI R Stormwater Program (with S 1-00 check if payl*nq by check) ate
Division of rnergy, Mineral R land Rpsour(p4; Stormwater Program
12 N Salic;btjry Street, 6,1- Flog (of f i(,p ()/ir)K)
IV, I M-,id SPrvi(p Pntpr
Rale'l'gho Nc 11699 1P,17
QT MAIL THIS FORM OR PAYMI Ni UNT11 YOUR APPI K.ATION HAS RFFM A(.(-,FPITFD AS COMPI,FTel
RK-1 YO Ll Ni All A4 k I!Aa R t COM P I F I I D WIT 14 AN OR 16 1 NA I Sir NATURE (NOT DIGITAtLl F R 122 . -2
I ic #L I A !)
F %. I F V %, %.Y E, r I U 9 V V1 tit C .& - - Z -1 -:). (:) (3 ( 1/0
I-'ertification in ony oPPIPCOtion., record, report,,plan, or othrr document filed of requited to be maintoinod undor this
Art41
icle or a rule implementing this Article ...shall hr guilty of a Clu-ss 2 misdemeanor which mayinrifvlp o fine not ro
exceed ter thousand dollars ($10,00o),
any person who knowingly makes any false statement,reprpe>entation, oi, , '�
lUnder penalty of law, I certify that (check all boxes to ifidirate your agreement).-
Q✓ I am the person responsible for the construction activitic; Of thl, project, for satisfying the requirements of
permit, and for any civil or criminal penalties incurred due t�, violat6ons of rhis permit.
U The information submitted in this N01 is, to the best of mv knowledge and belief, true, accurate, and compre'�e
based on my inquiry OT the person or persons who manage the system, Dr those persons directly responsible
gathering the information.
LKJ I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Erosion and Sediment Control Plan is not compliant with Part
Prevention Plan) of the NcGoinnnn General Permit I will nonetheless ensure
permit are met on the project at all times.
II (Stormwcater Pollution
that all conditions of Fart
II ot t;^e
hereby request coverage under the NCGO10000 General Permit and understand that cover = unriPr thic
permit will constitute the permit requirements for the discharge(s) and
individual permit'.
is enforceable in the same manner as an
Project Name (must march Ala).. Slavic Evangelic Church
01,00
Specific Lot Numbers (must match Alb): 6308 Nil"1111 Grove Road
Slavic Evangelic Church
Permittee (must match 81):
Legally Responsible Person (must match 82 & 83): Vasily Zhus[ima
Title of regally Responsible Person (must match B3b). President
Name Fs Title of Signed if Authorized Individual
Differs from Legally Responsible Person.,
Phone Nu ber,
7046689780MEW'
�
Signature of Legally Re'sponsibi Person or, Atj,,'t"40�
rize�i Individual
W.
1/5/22
�
Date
* IMPORTANT NOTE.$6 This �t�rrn rr,ust be siyr��ri by c, r�e,��,u���rbl� carpc�r�x�r. �th,cer that owns or operates the construction activity,
such as a president, secretary, treasurer, DI' vice presidetit, ur u rriUrIcryer that is authorized in accordance with Part IV, Section B,,
Item (15) of the NCGO10000 permit, �