NCC243072_NOI Signed Certification_20241009

NCGO1 Notice of Intent (N01) Certification Form
Directions
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NCDEMILRgormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury greet,6th Floor(Office 640K)
1612 Mail rvice Center
Raleigh, NC27699-1612
THE FORM YOUMa4ILMUSTI COMPLEED WITH ANORaNAL SIGNATURE(NOT DIGTAL)[40CFR122,22]
Per NCGeneral aatute 143-215.6B(i), any person who knowingly makes any falw 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 Gass 2 misdemeanor which may include 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.
E 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.
E✓ I will abide by all conditions of the NO 010000 General Permit and the approved Erosion and 3adiment Control
Ran.
0 If the approved Erosion and Sediment Control Ran isnot compliant with Part II (3ormwater Pollution
Prevention Ran)of the NCX010000 General permit, I will nonethelessensure that all conditions of Part II of the
permit are met on the project at all times.
[]✓ I hereby request coverage under the NCG010000 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.
Project Name(must match Ala): Bethesda Pines — Lots 1 -V 3
Specific Lot Numbers(mud match Alb): Lots 1 — 3
Fermittee(must match B1): Caviness & Cates Building and Development Co.
Legally Responsible Person (must match R2&B3): Patrick Raynor
Title of Legally Responsible Person(mud match B3b): Chief Financial Officer
Print Name&Title of 9gned if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 9107787902
10/2/24
5gnature of Legall onsible Person or Authorized Individual Date
* IMPORTANT NOTE This form must be signed by a resoonsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer,or vice prudent, or a manager that is authorized in accordance with Part IV, action B,
Item(6)of the NCL010000 permit.