NCC243062_NOI Signed Certification_20241009

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Print thisform, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NCDEIVILR3ormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources aormwater Program
512 N. Salisbury Greet, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC27699-1612
THE FORM YOU MAIL M UST BE COM PEED WITH AN ORIGINALSGNATURE(NOT DIGITAL)[40 CFR 122.221
Per NCGeneral Sat ute 143-215.68(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
Artide or a rule implementing this Artide. . . shall be guilty of a Class 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):
111 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.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and a-diment Control
Plan.
E✓ If the approved Erosion and:rudiment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NOG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I] I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirementsfor the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name(must match Ala): Brookstone Village, Phase One—Lot 86 and Phase Two— Lots 62 & 85
33ecific Lot Numbers(must match Alb): Lots 62, 85 & 86
Permittee(must 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: 91077873/2
10/2/24
Sgnature of Legall• sponsible Person or Authorized Individual Date
* IMPORTANT NOTE 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 pres dent, or a manager that is authorized in accordance with Part IV, action B
Item(6)of the NO3010000 permit.