NCC240168_FRO Submitted_20240209

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name
under which the company is Doing Business As. If the Financially Responsible Party is an individual,
General Partnership, or other company not registered and doing business under an assumed name,
attach a copy of the Certificate of Assumed Name.
Company DBA Name
•
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
T.E. ALLEN ENGINEERING, PC [e-mail]
Engineering firm or other consultant E-mail Address
Terry E. Allen, PE 828-553-3004 828-553-3004
Individual contact person (type or print) Phone: Office# Mobile#
The above information is true and correct to the best of my knowiecige and beiief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an
individual(s) or his attorney-in-fact, or if not an individual, by an officer, director, partner, or
registered agent with the authority to execute instruments for the Financially Responsible Party)_ I
agree to provide corrected information should there be any change in the information provided
herein.
tA mule mti4646 it Memw LL
Ty• ,t r prim . name 1` Title or Authority
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ilia 1 : I 1 j .- •• ' - Vil 0 26
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1, Arm- r f t , a Notary Public of the County of Lia_fe,„
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i that PO Y' appeared
State of - Imo, hereby certifyION � � PPS
personally before me this day and being duly sworn acknowledged that the above form was
executed by himlher.
-01
i tness my hand and notarial seal, this i day of ; r t 2Q, , 21#‘7_
I :
ary
Seal My commission expir
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yy: �or�a�r:�'=S a LAD�I.L JENNINGS
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tiff ; 1 My�on
�'••.,; ,; ;,..`� March 7p 2027