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<br />~NI1C1.\I.I til ~~\I 1': <br />I ),tlr IiIrJ: <br />R..;i~rJ Its' <br />Applicant/Anent Information <br />I do hereby certify that all information which I have provided for this application is, to the <br />best of my knowledge, correct. <br />12. Applicant Name <br />Representative Naine <br />Address <br />Phone <br />Fax <br />Signature <br />13. Agent Name (if any) / <br />Representative Name <br />Address <br />Coddle Creek Development Group, LLC <br />D.A. Davis <br />2404 Concord Highway, Monroe NC 28110 <br />704-291-7468 <br />Marc Frye <br />2404 Concord Highway, Monroe NC 28110 <br />Phone 704-361-3072 <br />Fax 704-292-7612 <br />Signature -~ <br />i <br />l <br />~'~U <br />Page 3 of 3 <br />