HomeMy WebLinkAboutNCC192593_Contact Update Record_20210119Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 1/19/2021 3:57:01 PM (Contact Changes Submitted)
•
Certificate of NCC192593
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-2593
Original NOI No.* 17919
Project information associated with this permit (cannot change):
Permittee Listed
Organizaiton cannot be changed (new CDC required)
Sampson Construction Co., Inc.
Project Name
Dormie Club - Clubhouse
Address
Beulah Hill Church Rd., West End, NC
County
Moore
Latitude
35.2601
Longitude
-79.5061
Date COC Issued*
11/12/2019
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Which Contacts
f Billing Only
Have Changed?*
r Legally Responsible Individual Only
f Site Contact Only
f BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
F No
r Yes
Billing Email
Billing Telephone
No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Ben Huck
Individual
(Previous)
First Name (New)* Ben
Last Name (New) * Huck
NEW Legally Fbflects any revisions above
Responsible Ben Huck
Individual*
Permittee Email ben.huck@sampson-construction.com
(Previous)
NEW Permittee ben.huck@sampson-construction.com
Email*
Permittee 4024345450
Telephone No.
(Previous)
NEW Permittee 4024345450
Telephone No.*
Permittee Mailing 3730 South 14th Street, 0, Lincoln, NE
Address (Previous) 68502
NEW Permittee
Mailing Address*
Street Address
5825 S 14th
Address Line 2
City
Lincoln
Fbstal / Zip Code
68512
Permittee Street 3730 South 14th Street, 0, Lincoln, NE
Address (Previous) 68502
NEW Permittee Street Address
Street Address* 5825 S 14th
Address Line 2
city
Lincoln
Fbstal / Zip Code
68512
State / Rovince / Fbgion
NE
Country
us
State / F rovince / Faegion
NE
Country
us
Change Requested Ben Huck
by: * Include any additional correspondence records in the %pository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 01 /19/2021