NCC230901_NOI Signed Certification_20230331

O
NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI. check at:
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by )
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6- Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per IVCGenero/Stotute 143-215.6E (fJ, any person who knowingly makes any false statement, representation, or
certification in any opp/icotion, record, report, plan, or other document fi/ed or required to be maintained under this
Artic%ororu/eimp/ementing this Article _ . _ shall be guilty of a Cl
ass 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, l certify that (check all boxes to indicate your agreement).
® lam the person responsible for the construction activities of this project, for satisfying the requirements of this
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, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
[� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part II (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.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
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): Cora Lane Farm House
Specific Lot Numbers (must match Alb): None
Permittee (must match BV: Margaret Viverito
Legally Responsible Person (must match B2 & 83): Margaret Vlverito
Title of Legally Responsible Person (must match B3b): Owner
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Num13'er:,407-9V/4152
ure
Legally Responsible Person or Authorized Individual
3 a ava3
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 that is authorized in accordance with Part Iv, Section B,
Item (6) of the NCGO1000o permit.