HomeMy WebLinkAboutNCC221742_NOI Signed Certification_20220512NC1301
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 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
Raleigh, NC 27699-1612
DO NOT MAIL
THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute
143-215.68 (i), any person who knowingly makes any false statement, representation,
or certification in any
gipplication, 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 a
ceed ten thousand dollars ($10,000).
Under penalty of law,
1 certify that (check all boxes to indicate your agreement):
x❑ 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.
x❑ The information
submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete based
directly responsible
on my inquiry of the person or persons who manage the system, or those persons
for gathering the information.
I will abide by
all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Co
itrol Plan.
IN If the approv
d Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention P
an) of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of
Part II of the
aermit are met on the project at all times.
❑x 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.
Name of Project: Cottages
at Wilson's Mills lots 2,4,5,8,10,14,21,22,23,37,40,41
Legally Responsible Organizational
Entity: Caviness & Cates Building and Development Company
Legally Responsible Person:
Christopher E. Cates
Title of Legally Responsible
Pers .
ice President
*Signature:
Date: 5/4 22
*Print Name and Title
Individual Differs from
of Signe ifA on
Permittee: Christopher E. Cates
Phone Number:
(910) 481-0503
*IMPORTANT NOTE: Th s 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 8, Item (6) of the NCGO10000 permit.
For more information o r7 signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.