NCC242436_NOI Signed Certification_20240812

NCGOI Notice of Intent (NQI) Certification Form
Directions:
Print thisform, complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DBVI LRaormwater Program (with$120 check if paying bycheck)
at:
Division of Energy, Mineral& Land Resourcesgormwater Program
512 N. Salisbury greet, 6th Floor(Office 640K)
1612 Mail service Center
Raleigh, NC27699-1612
THE FORM YOU MAIL M UST IEODM RETIED WITH AN ORIGNAL.SC NATURE(NOT DIGITAL)140 CFR122.22J
Per NCGeneral 3atute 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 2 misdemeanor which may indude a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxesto 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.
❑✓ 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.
0 I will abide by all conditions of the N03010000 General Permit and the approved Erosion and Sediment Control
Ran.
n If the approved Boson and Sediment Control Ran isnot compliant with Part II (3ormwater Pollution
Prevention Ran)of the N00010000 General Permit, I will nonethelessensure that all conditions of Part II of the
permit are met on the project at all times.
0 I hereby request coverage under the NCC3J10000 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.
Roject Name(must match Ala): Blakefield, Phase 8 — Lots 266, 267 & 286
43edfic Lot Numbers(must match Alb): Lots 266, 267 & 286
Permittee(mud match B1): Cates Building, Inc.
Legally Responsible Person(must match B2& B3): Christopher E. Cates
Title of Legally Responsible Person (must match B3b): President
Print Name&Title of Sgned if Authorized
Individual Differs from Legally Responsible Person:
Phone Number L D 8- Q&
8/9/24
Sgnature of Legally nsibl rson or Authorized Individual Date
* IMPORTANT NOTE This form must be signed by a reTonsble corporate officer that owns or operates the construction activity,
such asa president,secretary, treasurer,or vice president,or a manager that is authorized in accordance with Part IV, lion B,
Item(6)of the NO O10000 permit.