NCC193054_Contact Update Record (Legally Resp)_20220217

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 2/17/2022 8:12:04 AM (Contact Changes Submitted)

Certificate of NCC193054
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-3054
Original NOI No.* 19082
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Holder - Edison Foard - Leeper, A Joint Venture
Project Name CLT Terminal Lobby Expansion
Address 5501 Josh Birmingham Parkway, City of Charlotte, NC
County Mecklenburg
Latitude 35.2208
Longitude-80.9454
Date COC Issued * 12/06/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* • Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? • No
Yes
Billing Email [e-mail]
Billing Telephone No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible
Chad Smith
Individual (Previous)
First Name (New) *
Blake
Last Name (New)*
Long
NEW Legally
Reflects any revisions above
Responsible
Blake Long
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 6210 Old Ardrey Kell Road, Suite 400,
Address (Previous) Charlotte, NC 28277-1957
NEW Permittee Street Address
Mailing Address* 2330 Eatonton Street
Address Line 2
City
State / Province / Region
Charlotte
NC
Postal / Zip Code
Country
28208
us
Permittee Street 6210 Old Ardrey Kell Road, Suite 400,
Address (Previous) Charlotte, NC 28277-1957
NEW Permittee Street Street Address
Address* 2330 Eatonton Street
Address Line 2
City
State / Province / Region
Charlotte
NC
Postal / Zip Code
Country
28208
us
Change Requested Blake Long via Modification Request submitted 2/14/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 02/17/2022