NCC241996_NOI Signed Certification_20240723

y!CC
01 Notice of Intent (NOO Cer"ificat-on Form
Directions:
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the N[ DEK8LRStonnwater Program (with $120 check/f paying bycheck)
at:
Division of Energy, Mineral & Land Resources Stonnwa1erProgram
512N. Salisbury Street, 61, Floor(Office 64OK)
1612 Mai! Service Center
Raleigh, N[ I7699'l61Z
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification/n any application, record, report, plan, or other docunnentfiledorrequired to be maintained under this
Article n,o rule/nnp/exnent/ng this Article. . . shall be guilty ofo Class 2 misdemeanor which /noy include o fine not to
exceed ten thousand dollars ($10,080.
Under penalty of law, | certify that (check all boxes to indicate your agreement):
[�l | annthe person responsible for the construction activities ofthis project, for satisfying the requirements nfthis
permit, and for any civil or criminal penalties incurred due to vioiations of this permit.
[�l The information submitted in this NO| is, to the best ofmy 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,
��
�` / | will abide by all conditions nf the|NIO1U8O0 General Pe rrli't and the approved Erosion and Sediment Control
Plan.
�~ If the approved Erosion and Sediment Control Plan is not compliant with Part || (StonnvvaterPo||ution
Prevention Plan) of the NCG010000 Gerieral Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the Project at all times.
I hereby request coverage under the NCG010000 Gene,ral Permit and understand that coverage under this
permit will constitute the permit requirements for the disr-harge(s) and is enforceable in the same manner as an
individual permit,
Project Name (Must match A2o): Lot 194 H8seDtn8e
Specific Lot Numbers (must nnotchAlb): 194
^
Pennittee (must match Bl): Bluestone Bui\deFs, LLC
Legally Responsible Person (must match 83& B3): jDn8th@O Bluestone__________
Title ot Legally Responsible Person (must match 8Jb)� K�8OO�innK��Olb8[
-- -- ----- -------
Print Name /&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
--'--
h 911
---- 6/28/24
Sig LeEm||y, Keoponsib|e Person or Authorized |ndividua/ Date
'
- ,;T�0,TE: Thisfornn must be signed by a responsible corporate officer that owns or operates the construction activity,
opres� en, xperatofy, treasurer, or vice president, oru manager that isouthonizedhr accordance with Part IV,Section B,