NCC191122_Contact Update Record (Leg Resp Change)_20220812

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 8/12/2022 1:08:34 PM (Contact Changes Submitted)

Certificate of NCC191122
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-1122
Original NOI No.* 14121
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
AV Homes of Raleigh, LLC
Project Name Creekside at Bethpage Phase 5
Address 5283 Chin Page Road Parkway, Durham, NC
County Durham
Latitude 35.9011
Longitude-78.8294
Date COC Issued * 07/29/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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 [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Jeremy Medlin
Individual (Previous)
First Name (New)* Christian
Last Name (New)* Sheppard

NEW Legally Reflects any revisions above
Responsible Christian Sheppard
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 15501 Weston Parkway, Suite 100, 0, Cary,
Address (Previous) NC 27513
NEW Permittee Street Address
Mailing Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Permittee Street 15501 Weston Parkway, Suite 100, 0, Cary,
Address (Previous) NC 27513
NEW Permittee Street Street Address
Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Change Requested Christian Sheppard (Land Development Director) via Modification request submitted
by: * 8/2/2022.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 08/12/2022