NCC221172_Contact Update Record_20230510

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 5/10/2023 8:27:59 AM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC221172
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2022-1172
Original NOI No.* 84624
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Harnett Central Holdings
Project Name Kipling Village
Address Harnett Central Road,Town of Fuquay-Varina,NC
County Harnett
Latitude 35.4750
Longitude -78.8197
Date COC Issued* 03/30/2022
Prior Rescission Date This field will populate only if COC has already been rescinded.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
4) Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 919-669-3988
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Richard Van Tassel, II
Individual(Previous)
First Name(New)* Richard
Last Name(New)* Van Tassel, 11

NEW Legally Reflects any revisions above
Responsible Richard Van Tassel, II
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 1611 Jones Franklin Road Suite 101,0,
Address(Previous) Raleigh, NC 27606
NEW Permittee Street Address
Mailing Address* 1611 Jones Franklin Road
Address Line 2
Suite 101
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27606 us
Permittee Street 1611 Jones Franklin Road Suite 101,0,
Address(Previous) Raleigh, NC 27606
NEW Permittee Street Street Address
Address* 1611 Jones Franklin Road Suite 101
Address Line 2
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27606 us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Richard Van Tassel
(Previous)
Site Contact Title Managing menmber
(Previous)
Organization Harnett central holdings
(Previous)
First Name(New)* Rob
Last Name(New)* Lisle
NEW Site Contact* Reflects any revisions above
Rob Lisle

NEW Site Contact
Title
NEW Organization Insight
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 919-669-3988
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 1611 Jones Franklin Road,Suite 101,0,
Address(Previous) Raleign, NC 27606
NEW Site Contact Street Address
Mailing Address* 16255 Sussex Highway
Address Line 2
City State/Province/Region
Bridgeville DE
Postal/Zip Code Country
19933 us
Change Requested Jennifer V Erwin (Office Manager, Harnett Central Holdings)via Modification request
by:* submitted 5/9/2023.Also updated email address for R.Van Tassell noted on
correspondence provided with that request.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 05/10/2023