NCC231884_NOI Signed Certification_20230620

NCG01 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N0.
Then mail the urigina|formto the NCDEMLRStormwmte. Program (with $1DU check/f paying bv check)at:
Dk�yionofEnergy ��inera| �� Land Resources 5tonnwaterProgram
'
S1ZN. Salisbury Street,Gm Floor(Office 64DK)
1612 Mail Service Center
Raleigh, NC27699'1613
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST 0E COMPLETED WITH APWORIGINAL SIGNATURE(NOT DIGITAL) [40 CFIR 123.22]
9er0[Geneno/Jtotute143'22S.68(i), onypersnnw/hnknowing/ynnokesonyƒobestote/nent, represenbnbon, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article ororule implementing this Article. . . shall be guilty ofu Class 2 misdemeanor which may include o�oenot to
��ed�n�uuso»d��8o��1���. ^
Under penalty of|avv | c�rdfvthat (checha|| boyeo oindicate t
^ ` yourag,eenment):
P-1 I am the person responsible for the construction activities of this project, for satisfying the I-equirernents of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
��| The information submitted in this NO| is,tothe best of my knowledge and belief,true, accurate, and complete
basednnmyinquiryofthepeounorpersonsvvhomanaQethesystem.orthooepeonnsdirect|yrespunsib|efor
gathering the information.
��
c� | will abide by all conditions of the N(IS8I0O0O General Permit and the approved Erosion and Sediment Control
Plan.
�' If the approved Erosion and Sediment Control Plan is not compliant with Part || (Stormvvater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
[71 | hereby request coverage under the N{6Q1[00lGeneral 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 A1o): Abingdon
Specific Lot Numbers(must match A1b): 25
Permi1tee (must match B2\: Abingdon IOVe8tOr8, LLC
Legally Responsible Person (must match 82& 83): Kj8th8O Evans
Title of Legally Responsible Person(must match B3b): Manager
Print Name&Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 919-345-6729
t��f�%
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^t/gnazuneorme8a||ywespona|b|e Person or Authorized Individual Date
* /MPORT4mTNOTE. 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 f,
Item(6)oƒthe N[GODD00Dpermit.