NCC221887_NOI Signed Certification_20220613

Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
S12N.Salisbury Street, 6thFloor (Office 640K)
1612 Mail Service Center
Raleigh, NC27699'l612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute1���6B (i),mny person who knowingly makes mnyfalsestatement, representation,
orcertification /nany application, record, report, plan, urother doouovent/hedorrequired tubemaintained
under this Article ormrule implementing this Article ... shall beguilty ufoClass 2misdemeanor which may
include ofinenot toexceed ten thousand dollars ($14000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
X-1 |amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
X| The information submitted inthis NO|is, tothe best ofmyknowledge and belief, true, accurate, and
complete based onnnyinquiry ofthe person orpersons who manage the system, orthose persons
directly responsible for gathering the information.
X | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
CK If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions mf
Part Uofthe permit are met onthe project atall times.
IX | 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 manner msanindividual permit,
Name of Proiect: Beverly Place Ph3 Lots 156, 188-210
—Legally
8OH Raleigh, LLC
—Legally Responsible Person: G. Michael Kahm
Title of
Land Development
*S Date: --i~~-��—
*Print Name aV6 Titig/of Signed if Authorized
Individual Differs from Permittee:
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such asopresident, secretary, treasurer, or vice president, oromanager that is
authorized inaccordance with Part IV, Section B,Item (6)ofthe NCGO10000permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000penn/t.