NCC242307_NOI Signed Certification_20240807

N0001 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 NCDBUILR3ormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral & Land Fbsouroesaormwater Program
512 N. Salisbury Greet, 6th Floor(Office 64019
1612 Mail rvice Center
Raleigh, NC27699-1612
THEIR YOU MAIL MUST OE COM Pl...EITD WITH AN OR GNALSIGNATURE(NOTDIGTAL) [40 C R122.22]
Per NCGeneral aatute 143-215.6B(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report,plan, or other document filed or required to be maintained under this
Article or a rule implementing thisArtide_ . . shall be guilty of a Cass misdemeanor which may indude a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[] 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.
O 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.
O I will abide by all conditions of the N00010000 General Permit and the approved Erosion and Sediment Control
Ran.
O If the approved Erosion and Ssdiment Control Ran isnot compliant with Part II (Stormwater Pollution
Prevention plan)of the N0a10000 General Permit, I will nonethelessensure that all conditions of Part II of the
permit are met on the project at all times.
O I hereby request coverage under the NCG010000 General lermit 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 Ala): Maggie Way Subdivision Phase 3A Lots # 160 & 161
qoecific Lot Numbers(must match Alb): 160,161
Permittee(must match B1): Cates Building, Inc.
Legally Responsible Porson (must match 82&B3): Christopher E. Cates
Title of Legally Responsible Person(mud match B3b): President
Print Name&Title of 9gned if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: (910) 778-7 02
7/29/24
9gnature of Legally nsible Jerson or Atthorized Individual Date
* IMPORTANT NOTE This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such asa president, wcretary, treasurer, or vice president,or a manager that is authorized in accordance with Part IV, lion B,
Item(6)of the N03010000 permit.