NCC192014_Contact Update Record (Legally Resp Change)_20221024

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 10/24/2022 1:45:51 PM (Contact Changes Submitted)

Certificate of NCC192014
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-2014
Original NOI No.* 16163
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Ashe County Board of Education
Project Name Ashe County Middle School
Address AEV Lane, Jefferson, NC
County Ashe
Latitude 36.4250
Longitude-81.4805
Date COC Issued * 09/26/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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 Phyllis Yates
Individual (Previous)
First Name (New)* Eisa
Last Name (New) * Cox

NEW Legally Reflects any revisions above
Responsible Eisa Cox
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing PO Box 604, 0, Jefferson, NC 28640
Address (Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 604
Address Line 2
City
State / Province / Region
Jefferson
NC
Postal / Zip Code
Country
28640
USA
Permittee Street 320 South Street, 0, Jefferson, NC 28640
Address (Previous)
NEW Permittee Street Street Address
Address* 320 South Street
Address Line 2
City
State / Province / Region
Jefferson
NC
Postal / Zip Code
Country
28640
US
Change Requested Amanda Coldiron (Finance Officer) via Modification request submitted 10/17/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 10/24/2022