NCC215145_Contact Update Record (Address Update)_20241016

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 10/16/2024 3:58:15 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC215145
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-5145
Original NOI No.* 64610
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Crossroads Community LLC
Project Name Crossroads Community LLC
Address 20 S. Bear Creek Road,Asheville, NC
County Buncombe
Latitude 35.5621
Longitude -82.6077
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.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
O Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Beau McIntosh
Individual(Previous)
First Name(New)* Beau
Last Name(New)* McIntosh
NEW Legally Reflects any revisions above
Responsible Beau McIntosh
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 330 Franklin Road,0, Brentwood,TN 37027
Address(Previous)
NEW Permittee Street Address
Mailing Address* 1710 Camden Road
Address Line 2
City State/Province/Region
Charlotte NC
Postal/Zip Code Country
28203 us
Permittee Street 330 Franklin Road,0, Brentwood,TN 37027
Address(Previous)
NEW Permittee Street Street Address
Address* 1710 Camden Road
Address Line 2
City State/Province/Region
Charlotte NC
Postal/Zip Code Country
28203 us
Change Requested Joe Siddiqui (Site Contact)via emails on 10/7 and 10/16(signed update form).This
by:* change is an address update for the Legally Responsible Individual.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 10/16/2024