NCC191751_NOI Signed Certification_20190916

Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form tothe N[DEK8LRStormwaterProgram at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
6l3N.Salisbury Street, 6mFloor
I612Mail Service Center
Raleigh, N[Z7699-l6l2
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,
orcertification inany application, record, report, plan, wrother dommentfiledurrequired to be maintained
under this Article ororule implementing this Article . . . shall beguilty ufoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars /$I0'000/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
IX 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.
0] The information submitted in this NOI is, to the best of my 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.
IN | will abide byall conditions ofthe Permit.NCGO10000 General
and the approved Erosion and
Sediment Control Plan.
IN If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions nf
Part xofthe Permit are met nnthe project atall times.
IX | 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
somcmanner asanindividual permit.
Name of Project:
Legally Responsible Organizational Entity: Cates Building Inc
* Legally Responsible Person: Christopher E. Cates
Title of Legally Re5pon5i
. President
Date:Zu �/ �
*IMPORTANTNOTE. This 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 4Item (6)oƒthe N[G0I0000permit.