NCC191763_Contact Update Record (Billing)_20211021

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Selkane, Aziza 10/21/2021 7:37:40 AM (Contact Changes Submitted)

Certificate of NCC191763
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-1763
Original NOI No.* 15684
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
City of Raleigh
Project Name Brockton Drive Lake and Dam Project - Phase 2
Address Brockton Dr., Raleigh, NC
County Wake
Latitude 35.8420
Longitude-78.5970
Date COC Issued * 09/10/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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? U No
Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing 919-996-4023
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Richard Kelly
Individual (Previous)
First Name (New)* Richard
Last Name (New) * Kelly

NEW Legally Reflects any revisions above
Responsible Richard Kelly
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee 919-996-5576
Telephone No.*
Permittee Mailing 219 Fayetteville Street, Suite 801, Raleigh,
Address (Previous) NC 27601-1309
NEW Permittee Street Address
Mailing Address* 219 Fayetteville Street
Address Line 2
Suite 801
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27601-1309
us
Permittee Street 219 Fayetteville Street, Suite 801, Raleigh,
Address (Previous) NC 27601-1309
NEW Permittee Street Street Address
Address* 219 Fayetteville Street
Address Line 2
Suite 801
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27601-1309
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Barbara Moranta
(Previous)
Site Contact Title Senior Project Manager
(Previous)
Organization City of Raleigh
(Previous)
First Name (New)* Barbara
Last Name (New) * Moranta

NEW Site Contact* Reflects any revisions above
Barbara Moranta
NEW Site Contact Senior Project Manager
Title
NEW Organization City of Raleigh
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 919-996-3976
Telephone No.
(Previous)
NEW Site Contact 919-996-3976
Telephone No.*
Site Contact Mailing 127 West Hargett Street, 0, Raleigh, NC
Address (Previous) 27601
NEW Site Contact Street Address
Mailing Address* 127 West Hargett Street
Address Line 2
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27601
us
Change Requested Suzette Mitchell by email on 10/20/2021
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 10/21 /2021