NCC230035_NOI Signed Certification_20230109

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this farm, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with S100 check if paying by Check) at:
Divlston of Energv, Mineral & Land Resources Stormwater Program
512 N. Sali3bury Street, &, Floor (Office 640K)
1512 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL TMS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLMD WITH AN ORIGINAL SWiNATURE (NOT DlGfTAL) 140 CFR 122.221
Per NC General Stature 143.215.68 (i}, any person who knowingly makes any false statement, representation, at
certif►cption in any application, record, report., plan, or other document filed or required to be maintained under this
Article of a rule implementing this article shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($I0,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement)
[] I am the person responsible for the construction activities of this project. Far sattstying the requirements of this
permit. and for any cavil or criminal penalties incurred due to vinlalkms of this permit.
0 The information submitted in this NOI is, to the hest 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
garnering the information.
[]✓ 1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
0 It IIle approved Erosion and Sediment Control Plan is not compliant with Part 11 15turmwater Pollution
Prevention Plan) of the NCG010000 General r'e►mit- I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all time-,.
Q I hereby request coverage under the INC GO100 ]Q General Permit and uride rstand that coverage under this
permit will mristit►rte the, permit requirements for the discharge(s) and is enforceable +n the same manner as an
individual permit
Project Name (must Match Ala)- 252 Eaton Road, Mocksvilie, NC
Specific Lot Numbers ( must match A1b): 1
Permittee (mnusr march sty: La9(e Properties, LLC
Legally Responsible Person (must r+atch B2 & 83), Bradley Scott Lagle
Title of Legally Responsible Person (must match 93b): Member -Manager
Name & Title of Signed if Authorized Individual
Differs from Malty Resparisible Person;
Phone Number: .136'399-3821
Si nature of Legally tt pcinsible Person or Authorized individual Date
* IMPORTANT NOTE. Thi_ farm must besigned try a rexpons(blr carporurr officer that awns or operates the cunstrur ion arrivory,
$Loch as o president, serretary, treasurer, or vice president, or a marrager rhat r�t aurhonred rn accordance with Part IV, 5ectlan B,
item 16) of the NC6010" permit