NCC223936_NOI Signed Certification_20221123

NCG01 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic MOL
Then, mail the original form to the MC DEMLR Storrnwrater Program (with $100 check Jpvy6V by dieck at
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6* Floor (Office 64M
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATWN HAS BEM ACaVTW AS CONdPLiTE
THE FORM YOU MAIL muST BE OOMPLETEO WITH AM owwm 9GNAiURE (NOWT owffAn iw cFR 32z-m
Per NC General Statute 143-215.68 r), any person who knowingly mats arty false stateffmwt frP'mftWa6w. or
CrrtdkGtkM in any application, record, report; pillar, or other docrenent filled or required to be maintained under does
Artide or a rule implementing this Amide ... shall be guilty of a Class 2 misdemea►ar **irh n%W kK*.# le a fine not to
exceed ten thousand dollars ($10AOO)_
Under penalty of law, I certify that (check all boxes to indlkate your agreetnent):
❑✓ I am the person responsible for the construction activities of this project, for satisfying the requ remerits of dim
permit, and for any civil or criminal penalties incurred due to violations of this permit
✓� The information submitted in this NOI is, to the best of my knowledge and belief, true, accur rte, and complete
based on n y inquiry of the person or persons who manage the system, or those persons chrectty resportsibde for
gathering the information_
�✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sedrnent Control
Plan.
�✓ If the approved Erosion and Sediment Control Plan is not compliant with Part 11(Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit. I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
Q✓ I hereby request coverage under the NCG010000 General Permit and uniderstand that coverage under &is
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): Northside Estates
Specific Lot Numbers (must match Alb):1-15
Permittaee (must match 81): CMH Homes, Inc
Legally Responsible Person (must match 82 & B3): Frank Rogers
Title of Legally Responsible Person (must match 83b): manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number. 828-215-1261
Signature of Legally Responsible Person or Authorized Individual Date
IMP09TAIIIT MOTE Thisform must be signed by a response corporate of firer that owns or operates the construction activity,
such as a president, secretary, beasurer, or vice president or a manager that is authorized in accordance with Part N, Section 8,
/tem (6) of Me AIC60100010 permit