NCC233402_NOI Signed Certification_20231115

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 5120 check if paying by check)
at:
Division of Energy,Mineral& land Resources Stormwater Program
512 N.Salisbury Street,fe'I-loot (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL.MUST DE COMPUTED MTNANO1111111NAL SIGNATURE(NOT DIGITAL)(40 CFR 122.221
Per NC General Statute 143 215.68(I), any person who knowingly makes any false statement,representation, or
certification in any application,record, report,plan, or other document filed or required to he 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):
© 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_
EIZ I will abide by all conditions of the NCGO10O40 General Perth 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 protect at all times.
© 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,
Protect Name(must match Ala) Chapel Ridge Lot 34
Specific Lot Numbers(must match Alb): Lot 34
Permittee (must match 81): Prewitt Custom Homes, Inc.
legally Responsible Person(must match 82& 83): Jim Prewitt
Title of legally Responsible Person (must match 9 h) President
Print Name& Title of Signed if Authonzed
Individual Differs from legally Responsible Person_
Phone Number: 919,669.1969
11/14/203
Si ature a I e gally Rrwansibk.Person or Authorized Individual Date• -
IMPORTANT NOTE: This form roust be signed by a rrrEiciroibtr corporate officer that uwru ur ciprrutrs the cvrntructwn activity,
such as a president,secretary, treasurer, or vice president, or a manager that is outhorirrd in orrordanrr with Part IV,Section 9,
Item(6)of the NCG010000 permit.