NCC191028_NOI Signed Certification_20190723

NCG01 Notice of Intent (NOU) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form tnthe N[DEK4LR5tonnwa erProgram at:
Division nfEnergy, Mineral & Land Resources StonnvvaterProgram
5I2N.Salisbury Street, 6mFloor
1612 Mail Service Center
Raleigh, NC27699-1G12
Per NC General Statute 143-215,6B (i), any person who knowingly makes anyfalse statement, representation,
orcertification /nany application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofinenot to exceed ten thousand dollars ($14000).
Under penalty oflaw, | certify that (check all four boxes toindicate your a0reemeNd:
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.
W 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.
03 | will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
KI Ifthe approved Erosion and Sediment Control Plan isnot compliant with Part U(StonnwaterPollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project utall times.
DQ | hereby request coverage under the NCGO10000 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 asanindividual permit. ��,k Lx�i� �����
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Legally Responsible Organizational Entity: Cates Building Inc
* Legally Responxibhoeoon: Christopher E. Catcm-Prceidcot
Signature:
Date:
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.