NCC210951_Contact Update Record_20210318

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 3/18/2021 3:46:34 PM (Contact Changes Submitted)

•
Certificate of NCC210951
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2021-0951
Original NOI No.* 44619
Project information associated with this permit (cannot change):
Permittee Listed
Organizaiton cannot be changed (new CDC required)
Little Bear Creek Properties, LLC
Project Name
Beaver Creek Subdivision -Phase 1 B
Address
Claude Lewis Road, Dry Wells TWSP, NC
County
Nash
Latitude
35.7688
Longitude
-78.1801
Date COC Issued*
03/18/2021
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This field will populate only if COChas already been rescinded.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
r BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
F No
f Yes
Billing Email
[e-mail]
Billing Telephone
919-612-5531
No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible David Geiger
Individual
(Previous)
First Name (New)* David
Last Name (New) * Geiger

NEW Legally Fbflects any revisions above
Responsible David Geiger
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 919-612-5531
Telephone No.
(Previous)
NEW Permittee 919-612-5531
Telephone No.*
Permittee Mailing 755 Ranch Road, 0, Clayton, NC 27520
Address (Previous)
NEW Permittee Street Address
Mailing Address* 755 Ranch Road
Address Line 2
City
State / Rovince / Plegion
Clayton
NC
Fbstal / Zip Code
Country
27520
USA
Permittee Street 755 Ranch Road, 0, Clayton, NC 27520
Address (Previous)
NEW Permittee Street Address
Street Address* 755 Ranch Road
Address Line 2
City
State / Rovince / Region
Clayton
NC
Fbstal / Zip Code
Country
27520
USA
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact
David Geiger
(Previous)
Site Contact Title
Owner
(Previous)
Organization
Little Bear Creek Properties, LLC
(Previous)
First Name (New)*
David
Last Name (New) *
Geiger
NEW Site Contact*
Reflects any revisions above
David Geiger

NEW Site Contact Owner
Title
NEW Organization Little Bear Creek Properties, LLC
This field is not required on the NOI form and may not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 919-612-5531
Telephone No.
(Previous)
NEW Site Contact 919-612-5531
Telephone No.*
Site Contact Mailing 755 Ranch Road, 0, Clayton, NC 27520
Address (Previous)
NEW Site Contact
Mailing Address*
Street Address
755 Ranch Road
Address Line 2
City
Clayton
Fbstal / Zip Code
27520
State / Rovince / Fbgion
NC
Country
us
Change Requested David Geiger
by: * Include any additional correspondence records in the Fbpository 00Cfolder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 03/18/2021