NCC222871_NOI Signed Certification_20220822

NCGO1 Notice of Intent (NOU) Certification Form
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnxvaterProgram
S12N.Salisbury Street, G*Floor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
Per NCGeneral Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, orother docmnentfiledor required tobmmaintained under this
Article nrorule implementing this Article ... shall beguilty ofoClass 2misdemeanor which may include mfine not Co
exceed ten thousand dollars ($2D,UDO).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[-,| lam the person responsible for the construction activities of this project,for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[v-! 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, or those persons directly responsible for
gathering the information.
| will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
[v-� Ifthe 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 ofPart ||ofthe
permit are met on the project at all times.
[-1 | hereby request coverage under the NCGO10000 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 as an
individual permit.
Project Name (must match Ala): Pathway Triangle
Specific Lot Numbers (must match Alb): N/A
Perm ittee (must match Bl): BE&K Building Group, LLC
�BViO Lloyd
LegallyResponsible
Title of Legally Responsible Person (must match B3b): Sr. Project Manager
Name 8'Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number. `-
�q1,-A\7�1'OO54
*' -
Signature 6f 1-4ga-Ily- Responsible Pprs"6n or Authorized Individual Date
IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such as a president, secretary; treasurer, or vice president, or a manager that isauthorized /naccordance with Part IV, Section D,