NCC230763_NOI Signed Certification_20230322

NCG01 Notice of Intent (NO1) Celrt fi
Directions:
Print this form, complete, scan and upload to the
Then, mail the original form to the NC DEMLR Stormwater Program (In
Division of Energy, Mineral & Land Resources Stor
512 N. Salisbury Street, 6,1 Floor (Office
1612 Mail Service Center
Raleigh, NC 27699-1612
DO MYi MAlLTFii , FORM OP PATMENNT UNTIL YOUR APPLICATION
THE FORM YOU MAIL MUSTS[ COMPLETED tipITH. AN OPIGINAL SIGP
VoTtIMM
lectronic N01.
h $100 check if paying by check) at:
iwater Program
7�FEi CCEPTED AS C PLE E
RE(NOT OIGI T L) 740 CFP 122.22
Per NC General Statute 143-215.6B (i), any person who knowingly makes any also statement, representation, or
certification in any application, record, report, plan, or other document filed d 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 fine not to
exceed ten thousand dollars ($10,000}.
Under penalty of law, I certify that (check all boxes to indicate your agreemdht):
❑✓ 1 am the person responsible for the construction activities of this prol[ct, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violatio s of this permit.
[]✓ The information submitted in this NO] is, to the best of my knowledgil and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the syster i, or those persons directly responsible for
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 genera) Permit and t e approved Erosion and Sediment Control
Plan.
0 if the approved Erosion and Sediment Control Plans its not compliant 4ith Part I1 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, i will nonethele ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the IICGO10000 Goneral Permit an understand that coverage under this
permit will constitute the permit requirements for the discharge(s) a d is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): Forest Bluffs Estates Single Famif� Lots
c Lot Numbers (must match Alb): 1-74
Permittee (must match Bl): Massengill Design Build, LLC
Legally Responsible Person (must match 82 & B3): Blake Massengill II
Title of Legally Responsible Person (must match B3b): Member
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919.614.2911
6
Signature of Legally Responsible Person or Authorized Individual
Date
* IMPOKTANTNOTE: This form must be signed by a responsible corporate officer ti at owns or operates the construction activity,
such as a president secretary, treasurer, or vice president, or a manager that is o thorized in accordance with Part iv, Section B,
Item (6) of the NCG010000 permit.