NCC190787_Contact Update Record_20230804

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Tev.Holloman 8/4/2023 9:09:19 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC190787
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2019-0787
Original NOI No.* 12911
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
South Park Village, LLC
Project Name Southpark Apartments Phase II
Address Commerce Drive,Sanford, NC
County Lee
Latitude 35.4217
Longitude -79.1224
Date COC Issued* 06/28/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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
4) Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing (Optional)
Telephone No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Carter Keller
Individual(Previous)
First Name(New)* Carter
Last Name(New)* Keller

NEW Legally Reflects any revisions above
Responsible Carter Keller
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee 919-708-8987
Telephone No.*
Permittee Mailing PO Box 130, 0, Sanford, NC 27330
Address(Previous)
NEW Permittee Street Address
Mailing Address* PO Box 130
Address Line 2
City State/Province/Region
Sanford NC
Postal/Zip Code Country
27330 usa
Permittee Street 1600 Colon Road,0,Sanford, nc 27330
Address(Previous)
NEW Permittee Street Street Address
Address* 1600 Colon Road
Address Line 2
City State/Province/Region
Sanford nc
Postal/Zip Code Country
27330 usa
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Corey Mabus
(Previous)
Site Contact Title Project Manager
(Previous)
Organization Carolina Commercial Contractors
(Previous)
First Name(New)* Corey
Last Name(New)* Mabus
NEW Site Contact* Reflects any revisions above
Corey Mabus

NEW Site Contact Project Manager
Title
NEW Organization Carolina Commercial Contractors
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 910-728-5714
Telephone No.
(Previous)
NEW Site Contact 910-728-5714
Telephone No.*
Site Contact Mailing PO Box 130, 0, Sanford, NC 27331
Address(Previous)
NEW Site Contact Street Address
Mailing Address* PO Box 130
Address Line 2
City State/Province/Region
Sanford NC
Postal/Zip Code Country
27331 USA
Change Requested Mary Batchelor, Project Coordinator,via email on 8/4/2023.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 08/04/2023