NCC220709_NOI Signed Certification_20220210

NCCO1 Notice of Intent (NCI) Certification Forgo
Directions:
Print this farm, complete, Scan and upload to the electronic No I,
Them, mail the original forrn to the NC DEMLR Stormwater Program (with 5100 check ifpoying by check) at-
bivIsion of Energy, M inera l & Land Resources Storm ater Program
512 N. Salisbury Street, b+^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DD NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPtICATI!GN HAS BEEN ACCEPTED AS COMPLETE,
THE FpFt€1+1 YOU MAiL Mus'f sE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DICfTAL) 140 CFR 122.221
Per NC General Statute 143-215, 6B fl), any person who kri ouwfrrgly makes ony false statement, representation, or
certr`ficotfon in any application, record, report, plan, or other documet?e filed or required to be maintained under this
Article or a rule Fmplementrrrg this Article ...shall be guilty of a Class 2 misderneanor which may include o fine not to
exceed tern thousond dollars ($10,000)-
Under penalty of law, I certify that (check all boxes to indicate your agreement):
F-7 I I am the person responsi ble far the construction activities of this project, for satisfying the requirements of this
permit, and for any civil ar cri urinal Pena Ities incurred due to violabon5 of this permit.
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, cr those persons directly responsible for
gathering the information-
wil I abide by all conditions of the NCG0.10000 General Permit and the approved Erosion and Sediment Control
Plan.
7 If the approved Erosion and Sediment Control Plan is not compliant with Part I I (Stormwater Pollution
Prevention Plan} of the NC601.O000 General Permit. I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
Q 1 hereby request coverage under the NC O.10000 Gene.ra.I Permit a nd 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.
Project Narne (must match Al a), Vie s at Reems Creek
,Specific Lot Nurnber5 (must match Alb):
Permittee (must march BS): Skyburn Group LL
Legally Responsible Person €mast match B2 & B3}: Stephen
Title of Legally Responsible Person (mast match B3b): toneburner
Nance & Title of Signed if Authorized Individual
Differs from Leeafly Resnonsibie Person: Registered Agent
Phone Number, [phone]
.Signaturefof Legally Respansib€e Person or Authorized Individual
Awe
IMPORTANT NOTE. Thhs form must be sign,Cd by o m.5porWble Corporate officer that owns or operates the constriction activity,
such as a presiderrt, secretary, treasurer, or vice presiden � or a m imager that is authorized in accordance with Part I4V, Section 8,
Wm (6) of the NC 010000permit.