NCC216446_Contact Update Record (Leg Resp and Site Contact)_20221110

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 11/10/2022 7:47:22 AM (Contact Changes Submitted)

Certificate of NCC216446
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2021-6446
Original NOI No.* 73258
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Habitat for Humanity of Wake County
Project Name Flowers Place Subdivision
Address Flowers Street, Knightdale, NC
County Wake
Latitude 35.7856
Longitude-78.4763
Date COC Issued* 11/22/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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
[e-mail]
NEW Billing Email
[e-mail]
Billing Telephone No.
9197442413
NEW Billing
[phone]
Telephone No.
(Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Robert Ahern
Individual (Previous)
First Name (New)* Patricia
Last Name (New)* Burch

NEW Legally Reflects any revisions above
Responsible Patricia Burch
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 2420 North Raleigh Boulevard, 0, Raleigh,
Address (Previous) NC 27604
NEW Permittee Street Address
Mailing Address* 2420 North Raleigh Boulevard
Address Line 2
City State / Province / Region
Raleigh NC
Postal / Zip Code Country
27604 United States
Permittee Street 2420 North Raleigh Boulevard, 0, Raleigh,
Address (Previous) NC 27604
NEW Permittee Street Street Address
Address* 2420 North Raleigh Boulevard
Address Line 2
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27604
Wake
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Jim Middleton
(Previous)
Site Contact Title Director of Land Acquisition & Development
(Previous)
Organization Habitat for Humanity of Wake County
(Previous)
First Name (New)* Jamie
Last Name (New)* Pennington
NEW Site Contact* Reflects any revisions above
Jamie Pennington

NEW Site Contact Construction Administration Manager
Title
NEW Organization Habitat for Humanity of Wake County
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 9197442413
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 2420 North Raleigh Boulevard, 0, Raleigh,
Address (Previous) NC 27604
NEW Site Contact Street Address
Mailing Address* 2420 North Raleigh Boulevard
Address Line 2
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27604
United States
Change Requested Jamie Pennington (Construction Administration Manager) via Modification request
by: submitted 11/9/2022. New CEO.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 11 /10/2022