NCC231903_NOI Signed Certification_20230620

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMI_R Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street. 6-- Floor (Offii f` 1)AOK)
1612 Mail vic e Center
Raleigh,
DO NOT MAIL THIS FORM OR PAYMENT"
THE FORM YOU MAIL MUST BE COMET' , I I,,
Per NC General Statute 143-215.68 (i), any person who knov ,,, ; . ,':., ptation, or
certification in any application, record, report, plan, or other r1c.... • • under this
Article or a rule implementing this Article . . . shall be guilty of a ;p fine riot to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Q✓ I am 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.
Q✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
E✓ 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.
Q✓ I hereby request coverage under the NCG010000 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): Sidbury Farms Phase 2
Specific Lot Numbers (must match Alb):
Permittee (must match 81): D.R. Horton, Inc. Libby Shelton
Legally Responsible Person (must match 82& 83): L)•hbv 1/1e. 1.4'
Title of Legally Responsible Person (must match 83b): Vice President
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsible Person: Donald Aiken Assistant Secretary
Phone Number: 910-508-0017
6/13/23
eSignature of Legally Responsible Person or Authorized Individual 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 NCG010000 permit.