NCC222748_NOI Signed Certification_20220803

Dacu5ign Envelope ID: 354C
3753-45F D-9534-155656B2C332
NCG01 Notice of Intent (NOI) Certification Form
Then, mail the of
Do NOT MAIL'
THE FORM YOU I
Directions:
Print this form, complete, scan and upload to the electronic N01.
iginaI farm to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6Th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
IS FORM 0R PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
ill. MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE [NOT DIGITAL] [40 CFR 122.22)
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any app lication, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implery enting 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, [[certify that (check all boxes to indicate your agreement):
❑✓ I am the perso responsible for the construction activities of this project, far satisfying the requirements of this
permit, and fa any civil or criminal penalties incurred due to violations of this permit.
Q The informatit submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based ❑n my i quiry of the person or persons wh❑ manage the system, or those persons directly responsible for
gathering the J
formation.
❑✓ 1 will abide by II conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the a pp rovei I Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention PI ) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are me on the project at all times.
0 I hereby req uie st coverage under the NCG010000 General Permit and understand that coverage under this
permit will co tit.
titute the permit requirements for the discharge(s) and is enforceable in the same manner as an
per individual
Project Name (m
Specific Lot Num
match A1a1: ACC Blvd Townes
(must match Alb):
Permittee jmust mach 81): Blue Heel Development LLC
Legally Responsibli Person tmust match B2 & B3j: Julie Gavaghan
Title of Legally Responsible Person (must match 83b): COO
Name & Title of Si.1ned if Authorized Individual
Differs from Leeall Resoonsible Person:
Phone Number: 919-800.0460
--uSign by:
Ily Resp6nsible Person F Vruthorized Individual
7/27/20
Date
* IMPORTANT NOTE: is form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president stretory, treasurer, or vice president, or a monager that is authorized in accordonce with Port IV, Section B,
item (6) of the NCG01000 permit.