NCC201608_Contact Update Record (Legally Resp Change)_20230315

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/15/2023 12:37:06 PM (Contact Changes Submitted)

Certificate of
NCC201608
Coverage (COC) No.*
Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No.
NCG01-2020-1608
Original NOI No.*
24596
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
City of Greensboro
Project Name Contract 2011-067, Alamance Church Road Improvements
Address Alamance Church Road, Greensboro, NC
County Guilford
Latitude 36.0359
Longitude-79.7598
Date COC Issued * 04/29/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
n 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 John Fersner
Individual (Previous)
First Name (New)* Jason
Last Name (New)* Geary

NEW Legally Reflects any revisions above
Responsible Jason Geary
Individual*
Permittee Email
[e-mail]
(Previous)
NEW Permittee
[e-mail]
Email*
Permittee Telephone
336-373-2302
No. (Previous)
NEW Permittee
[phone]
Telephone No.*
Permittee Mailing Post Office Box 3136, 0, Greensboro, NC
Address (Previous) 27401
NEW Permittee Street Address
Mailing Address* Post Office Box 3136
Address Line 2
City
Greensboro
Postal / Zip Code
27402-3136
State / Province / Region
NC
Country
USA
Permittee Street 300 West Washington Street, 0, Greensboro,
Address (Previous) NC 27401
NEW Permittee Street Street Address
Address* 300 West Washington Street
Address Line 2
City
State / Province / Region
Greensboro
NC
Postal / Zip Code
Country
27401
USA
Change Requested Jason S. Geary, P.E. (City Engineer) via Modification request submitted 3/13/2023.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/15/2023