NCC242009_NOI Signed Certification_20240723

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NCGOI Notice of Intent (NOO Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO|.
Then, mail the original form to the N[ DEMLRStormwater Program (with $lZO check if paying by check)
at:
Division of Energy, K4inerai & Land Resources StornnvvaterProgram
S1JN. Salisbury Street, 6m Floor(Office 64OK)
l622 Mail Service Center
Raleigh, NC27G99'161Z
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statenient, 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 of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($20,0U0,).
Under penalty of law, | certify that(check all boxes-tmindicateVouragreemnent):
[V_l / amthe 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,
[�l The information submitted in this ND| is,to the best of my knowledge and belief,true,accurate, and complete
bajed on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
[�l
c�� | wi|| abidebya|| conditiunsoftheN[GO10OOOGene/a| PernoitandtheapprovedErosionandSedinnentCnntro|
Plan.
Fv_1 If the approved Erosion and Sediment Control Plan is not compliant with Part If (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met onthe project at all times.
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): Lot 22, Sanctuary @t Lake Wheeler
Specific Lot Numbers(must match A2b): 22
Permittee (must match 82): Bluestone Builders, LLC
Legally Responsible Person (must match BJ& 83): jOn2thGD BlU8StOOG
Title of Legally Responsible Person (must match 83b): Managing Member
Print Name&Title uf Signed ifAuthorized
Individual Differs from
' Legally Responsible Person:
Phone Number: 919-870-7734
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Sign of Legally Responsible Person or Authorized Individual ` D te
* 0NpORT40T�� Th�fbnn must bo signed byo responsible corporate o�ce/that owns oropeno�s the construction �uct/onoct/v/�
such osopms�on�secretary, treasurer, o/vice president, uro manager that is authorized/n accordance with Part IV,Section 8'
Item(6)n/the NCGO20000permit.