NCC190500_Contact Update Record_20210804

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 8/4/2021 11:10:39 AM (Contact Changes Submitted)

•
Certificate of NCC190500
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-0500
Original NOI No.* 11774
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new CDC required)
Kevin Walsh
Project Name
Stevens Grove - Lot 46
Address
1025 Arborfield Drive, Matthews, NC
County
Mecklenburg
Latitude
35.1053
Longitude
-80.7594
Date COC Issued*
06/05/2019
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This field will populate only if COChas already been rescinded.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 Kevin Walsh
Individual
(Previous)
First Name (New)* Kevin
Last Name (New) * Walsh

NEW Legally Peflects any revisions above
Responsible Kevin Walsh
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 2406601678
Telephone No.
(Previous)
NEW Permittee 2406601678
Telephone No.*
Permittee Mailing 517 Nelson Drive NE, 0, Vienna, VA 22180
Address (Previous)
NEW Permittee Street Address
Mailing Address* 517 Nelson Drive NE
Address Line 2
City State / Rovince / Fbgion
Vienna VA
Fbstal / Zip Code Country
22180 USA
Permittee Street
517 Nelson Drive NE, 0, Vienna, VA 22180
Address (Previous)
NEW Permittee
Street Address
Street Address*
517 Nelson Drive NE
Address Line 2
City
State / Fkovince / Region
Vienna
VA
Fbstal / Zip Code
Country
22180
USA
Change Requested Kevin Walsh
by: * Include any additional correspondence records in the Repository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date *
08/04/2021