NCC221690_NOI Signed Certification_20220503

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01, check) at:
Then, mail the original form to the NC DEMges Stovr watOith �P Progrcheck if am
by
Division of Energy, Mineral & Land Resour
512 N. Salisbury Street, 6th Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS AN ORIGINAL SIGNATURE (NOT DIGITAL) [40O FRP122.22]
THE FORM YOU MAIL MUST BE COMPLETED WITH
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
0 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.
Q✓ The information submitted in this N04 is, to the best of �knowledge
sie
l sm
dand directly
resdpansibcomplete
for
based on my inquiry of the person or persons who manage the Y
gathering the information.
QNCG010000 General Permit and the approved Erosion and Sediment Control
I will abide by all conditions of the
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
I will nonetheless ensure that all conditions of Part II of the
Prevention Plan) of the NCG010000 General Permit,
permit are met on the project at all times.
ge under this
erstand that
vera
Q I hereby request coverage under the NCG010000 Gthe discharge(s)mit nand is enforceable inthesame manner as an
permit will constitute the permit requirements for
individual permit.
Project Name (must match Ala):
Old Fork Village
Specific Lot Numbers [must match Alb):
6963-50-7956
Permittee (must match B1): Old Town Road, LLC
Legally Responsible Person (must match 62 & 0:
Adam Stewart
Title of Legally Responsible Person (must match B3b):
Owner
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: [phone]
4/29/22
Date
Signat e o Legally Responsibl erson or Auth zed individual
erates the construction octivitY,
IMPORTANT NOTE, This form must be signed by a responsible corporatenrh officer is authorized inra� accordance with Pat IV, Section B,
such as a president secretary, treasurer, or vice president,
Item (6) of the NCG010000 permit.