NCC243247_NOI Signed Certification_20241023

N0001 Notice of Intent (NO1) Certification Form
Directions
R-int thisform,complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DBV1 LRStormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral& Land ResourcesStormwater Program
512 N.Salisbury Street,6'',Floor(Office 6401c1
1612 Mail Service Center
Raleigh, NC27699-1612
THE F OU MAILM UST BECOMPLC WITH ANO1 NAL SIGNATURE(NOT DIGTAL)[40 CFR 122.22]
Per NC General S of ute 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 Class 2 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.
✓❑ 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 Sediment Control
Ran.
n If the approved Erosion and Sediment Control Ran is not compliant with Part II (aormwater Pollution
prevention Ran)of the NO2010000 General Fermit, I will nonethelc censurethat all conditions of Part II of the
permit are met on the project at all times.
✓0 I hereby request coverage under the N00010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges)and is enforceable in the same manner as an
individual permit.
Project Name(must match Ala): Elliot Farms, Phase 1 B — Lots 22, 23 & 42
Specific Lot Numbers(must match Alb): 22,23, & 42
Permittee(must match B1): Caviness & Cates Building and Development Co.
Legally Fesponsible Person (must match 82&83): J Patrick Raynor
Title of Legally Responsible Person(must match B3b): Chief Financial Officer
Print Name&Title of Sgned if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: [phone]
10/21/24
gnat ure of Lega tylespuiisible Person or Authorized Individual Date
* 1M NOTE This form must be signed by a re. onsibte 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, fiction B,
Item(6)of the N03910000 permit.