NCC223607_NOI Signed Certification_20221020

NI: 01 Notice of Intent (N01) Certification farm
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC 0EMLR Stormwater Program (with 100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,1- Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPOCATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE INOT DIGITAL) [40 CFR 12222]
Per NC General Statute 143- 15.66 (r'), any person who knowingly makes any false statemernt, representation, or
certification in any application, record, report, plain, or other docurnent filed or required to be maintoined under this
Article or a rule implementing this Article ... $hail be quif€y of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand doliors ($10,000).
Linder penalty of lativ, I Certify that {check all boxes to indkate your agreement:
0 I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, anti for any civil or criminal penalties incurred due to vio[aI.ions of this permit_
Q The information submitted in this N01 is, to t lie best of my lulowledge and belief, true, accurate, and complete
based oil nny inquiry of the person or persons who manage the systeni, or those persons directly responsible for
gathering the information.
El I will abide by all conditions of the NCGQ10000 General Perrn.it acid t1ic approved Erosion ailed Sediment Control
Plan_
0 if the approved Erasion and Sediment Control Plan is not com pliant with Part Ii (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of tine
permit are met on the project at all times.
© I hereby request coverage under the NCGO10000 General Permit and understand that coverage undar this
permit will constitute the permit requirements for.Ise discharge(SM and is enforceable in the same manner as an
individual Permit.
Project Narne (must match Ale): curitrywoods Ph 1 Grading
Specific lot Numbers (must match AIh); /A
Perm ittee (must match 811: ountry cods Comrnun4, Ll_G
Legally Responsible Person (rnust match 82 & B3): Kenyon Burnham
Title of Legally Responsible Person [must match 63h1- Manag!ng Member
Marne & Title of Signed 4 t orized Individual
Differs from Legally Re, onsfbie Person
Prone Numb . f �� � o lc?
of
ble Person Authorized Individual
Ia
C} e
* IMPORTANT This form must be signed by o responsible corporate officer that owns or aperutes the construction activity,
such as a president, secretary, treasurer, or vice presidehrr#, or a manager tlxrt is outhori2ed irf accordgnee with Part IV, Section $
stern (6) of the NC6010000 Permit_