NCC190451_Contact Update Record (Legally Resp Change)_20230323

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/23/2023 11:58:08 AM (Contact Changes Submitted)

Certificate of NCC190451
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-0451
Original NOI No.* 11655
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
City of greensboro
Project Name Contract 2018-020, Summit Avenue Streetscape Improvements
Address Summit Avenue, Greensboro, NC
County Guilford
Latitude 36.0807
Longitude-79.7803
Date COC Issued * 06/04/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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? 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 Ted Kallam
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
[phone]
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 Geary via Modification request submitted 3/22/2023.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/23/2023