NCC191509_NOI Signed Certification_20190829

Print this form, complete, scan and upload to the electronic N0L
Then, mail the original form tothe NCDEK4LRStormvvate/Program at:
Division of Energy, Mineral & Land Resources SturmeaterProgram
5I2N.Salisbury Street, 6mFloor
I612Mail Service Center
Raleigh, NC27699-I6lZ
Per NC General Statute 143-215.613 (i), any person who knowingly makes onyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall beguilty ofoClass 2misdemeanor which may
include ofine not &oexceed ten thousand dollars /$1(lD00/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
O8 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.
CR The information submitted inthis N0is, tothe best ofmyknowledge 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.
IN | will abide bvall conditions ofthe —
and the approved Erosion and
Sediment Control Plan. �---
CR if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe |wiU nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
IN | hereby request coverage under the NCGO10000 General Pe mit and understand that coverage under
this permit will constitute the permit req i t ��-------
ur�m�n �lo/TUe d|scharge(s)and isenforceable inthe
same manner asanindividual permit.
Name of Project:
Legally Responsible Organizational Entity: Caviness & Cates Building and Development Company
Legally Responsible Person: Ch ristopher F, Cates
Title ofLegally Responsible Person: Vice Presiduit
Date:
*
IMPORTANTNOTE. This form must be signed by a responsible corporate officer that owns or operates the
con5truction activity, such os o president, secretory, trocsurer, or vice president, or a manager that is
authorized in accordance with Port IV, Section B, Item (6) of the NCGO10000 permit,
For more information onsignatory requirements, see Part IV, Section B'Item (6)o/the N[GOJO0ODpermit.