NCC242873_FRO Submitted (4)_20240923

Partnership,or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DSA Name
(d) if order to facilitate Express Permitting, It is necessary to bo able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
N/A
Engineering firm or other consultant E-mail Address
Individual contact person (type or print) Phone: Office# Mobile#
The above information is true and correct to the best of my knowledge and belief 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.
Correia Construction Company LLC Kevin Correia, owner
Ty e or print name Title or Authority
_.6.414124- \DA(y..L,
Signature Date
I, /`S Q , a Notary Public of the County of S p. 54/)
State of North Carolina, hereby certify that ,P f>/V CD 1'C,t ft appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, th2e day of 20 q2 y
Seal My commission expires
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