20150537 Ver 1_Application_20150601 (2)

4. Applicant Information (if different from owner)
4a. Applicant is: ❑ Agent � Other, specify: NCDOT Division Engineer for Division 3
4b. Name: ar /►��ren Co llg -F�C'. � E, rv,•, 6ii�15
4c. Business name NC Department of Transportation
(if applicable):
4d. Street address: 5501 Barbados Blvd.
4e. City, state, zip: Castle Hayne, NC 28429
4f. Telephone no.: 910-341-2000
4g. Fax no.: 910-675-0143
4h. Email address: n/a
5. Agent/Consultant Information (if applicable)
5a. Name: Stonewall Mathis
5b. Business name NCDOT
(if applicable):
5c. Street address: 5501 Barbados Blvd.
5d. City, state, zip: Castle Hayne, NC 28429
5e. Telephone no.: 910-341-2036
5f. Fax no.: 910-675-0143
5g. Email address: [e-mail]
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PCN Form — Version 1.3 December 10, 2008 Version