NCC230042_NOI Signed Certification_20230106

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NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO I.
Then, mail the original form to the NC DEMLR Stormwa ter Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6m Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
❑O NOT MAIL TH15 FORM OR PAYMENT UNTIL YOUR APPLICATION HA5 BEEN ACCEPTED AS COMPLETE.
V N.7 OL L.V N � ]iL]I►HfUnL I.VLf '- L 122.22
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or ocher document filed or required to be maintained under this
Article or a rule implementing this Article... shall be guilty of a Class 2 misdemeanor which may include a f ine not to
exceed ten thousand dollars ($10,000).
Under penalty of lava, I c:eriiiy that (chockall boxes it) indi:::a a lmur atp-tmraetit):
I am the person rosponsitile for the c:oristruction at:tivities of this project., for ssatisfyirig i:h;: rerluireinerits of this -
perm it, acid for any cavil or crirri1nal penalties incurred due to violations a{ this perm ii;,
® The information subiviitted in this NO is, to the hest of my knowledgre iaiit] belief, true, accurate, and completo
based on my inquiry of Lhv rx-,Non or persons who manage the system, or those persons directly responsible for
gathering the irifOrmation.
1177
I will abide kry all c ooditions of the NCG010000 General Permit and the approved Irosican dnd 5caditnzrrt Control
Plan.
MW
If the approved Frosion acid Sedifnent Control Plari is not comp Iiwit with I'art II (Stormwaater PoIlution
Prevention Plan) of the NC:G010000 General Permiti will nonetheless ensure that all corklitimis cif Part 11 of
permit are milt on the prof" at all times.
jZW
I hereby reclric A coverage under the NCG010000 General Permit and understand that coverage under this
permit wiII cons 11iute the perm ii req ui rern mits for the discharge(s) and is enfoi coable in tlic sarfic rtiariner ;is ari
individual permit.
Proiect Name (must match Ala): Jones Residence
Specific Lot Numbers (must match Alb): 2100 Paradise Harbor Dr.
Perm ittee (must match 81): Blair & Ann Jones
Legally Responsible Person (must match 82 & 83): Blair Jones
Title of Legally Responsible Person (must match 63b): Owner
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 404.520.6011
Signature of Legally ponsible Person or Autho ized 4561' rdual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction: activity,
such as a president, secretary, treasurer, or vice president, or a manager shot is authorized in accordance with Part IV, Section 8,
item 16) of the NCGO10000 permit.