NCC233051_NOI Signed Certification_20231011

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NCGO1 Notice of intent (N00 Certification Form [
Directions:
Print this form,complete,scan and upload to the electronic NOI.
Then,mail the original form to the NC DEMLR Stormwater Program(with$100 check if paying by check)at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
'r-
Raleigh, NC 27699-1612
Per NC General Statute143-215.66(0, any person who knowingly makes any false statement,representation,or
[certification in any application,record,report,plan, or other document filed or 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 agreement):
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[] I am the person responsible for the construction activities of this project,for satisfying the requirements of this 1,
[permit,and for any civil or criminal penalties incurred clue to violations of this permit.
Exi The information submitted in this NOHs,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 i.
gathering the information.
E< I will abide by all conditions of the fICGOltt0Q0 trepetral permit and the approved Erosion and Sediment Control
Plan.
al If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Pollution
Prevention Plan)of the Ne6030000 Genre aNtre mi.!, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
El I hereby request coverage under the moo-room crocm RN:0N 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.
Lot 741 Ridge
Project Name(must match Ala): Chapel
[
Specific Lot Numbers(must match Alb): 741 [
Inc.
Permittee(must match 81): Prewitt Custom Homes,
Legally Responsible Person(must match 82& B3): Jim Prewitt 1
Title of Legally Responsible Person(must match B3b): President
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
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9196691969
Pho Number:_cs\
10/9/2023
Signature of Legally Responsible Person or Authorized Individual Date
IMPO ANT 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 13,
Item(6)of the NCGO:10000 permit.
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