NCC240351_NOI Signed Certification_20240209

NK`GO1 Notice of Intent (NO[) 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 ResourcesStormoxvater Program
S12N. Salisbury Street, 6`^ Floor(Office 64OK)
16l2 Mail Service Center
Raleigh, N[27699'l612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED ASCOMPLETE.
THE
~ FORM YOU MAIL
~~ ~MUST"B- COMPLETED~ F[~ N|ORIGINAL
~SIGNATURE" ^~(NOT||DIGITAL)` �~ ~~CF~ 122'22l Per/V[General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
/ �h do ���dorrequ�edtobenno/ntu/nedunderth�
oer��to�on /nonyopp�to�on' recon� repor�pm� urn other cunmen '
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 ($2(l000}.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
�
—| | amthe person responsible for the construction octivideso[this pnject, for sadsfvinQthe requirenoentsofthis
� permit, and for any civil or criminal penalties incurred due to violations of this permit.
�-1 The information submitted \n this N0 i�to the best of my knowledge and belief,true, accurate, and complete
stern
based onmy inquiry of the person orpemonswh �h u manage esy ,or those persons directly responsible for
gathering the information.
F—) { will abide by all conditions ofthe NCGO10000 General Pernit and the approved Erosion and Sediment Control
Plat).
[-Vl |f the approved Erosion and SedinoentControl Plan is not compliant vvithPart U (SturmwaterPoUution
PoevendunP|an)oftheNCGO1O0OUGeneraiPe/mit, | xviUnonethe|essensuvethataUconditinnoo|Part \| ofthe
permit are met unthe project at all times.
�-1 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 A1u): Sunshine Meadows Phase 2 Section 4
Specific Lot Numbers(must match A2b): 37-47; 51-54
Permittee (must match 81): SYJRC. Inc.
Legally Responsible Person (must match BJ& B3): Kenneth C@n@dV
Title of Legally Responsible Person (must match 83b): President
Print Name&Title uf Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 919-741-1717
�7 - � �� ��+, �/
/ ~
^���nature^--e}a||yKespnhsi |e Person or Authorized Individual Date
* /MPQRT4xUrNOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such osopresident,secretary, treasurer, o/vice president, oro manager that is authorized/n accordance with Part IV,Section B,
Item(6)of the NC6020000permit.