NCC240112_NOI Signed Certification_20240112

NC(7741 N*t^c,-- *f lKYt,--,nt (N*11) Ctrt^f^c.,-t^*n F*rr-----i,
Directions:
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLRStornnwater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources StornnvvaterProgram
S12N.Salisbury Street, 6th Floor(Office 64OK)
161Z Mail Service Center
Raleigh, NC27699'1612
THE
~~R'I YOU N7AIL MUST—~~-�-~--~~--/m~°~—^--COMPLETED
--^-WITH
--`--~—'--~~ORIGINAL SIGNATURE
^~- DIGITAL)(—'~--- -~~~-'—,~-- 22}
Per NCGeneral Statute 243-2J5.6B (i) any person who knowingly makes onyfabcstatement,representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article nro rule implementing this Article . . . shall be guilty ofoClass 2 misdemeanor which may include o fine not to
exceed ten thousand dollars/$1(lODOV.
Under penalty of law, | certify that (check all boxes to indicate your agreement):
[v-11 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.
[71 The information submitted in this NO| is,tnthe best ofmy 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.
[�
c� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Fvv If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater 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.
[�l 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 A1o\: Amplify Church E%D8nSiOO
Specific Lot Numbers(must match A2b>:
Permittee (must match 8l): Phillip MOd|iO
Legally Responsible Person (must match 826& 83): Phillip MOdliO
Title of Legally Responsible Person (must match 83b): P@8tO[
Print Name &Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number:
Signature Legally� Responsib|ePeraznorAutho,ized |ndk/idua| Date
y �
~ 0MPORTANTNDTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as president,secretary, treasurer, or vice president, or manager that is authorized in accordance with Part IV,Section E,