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HomeMy WebLinkAboutNCC191946_Contact Update Record_20240920 Action History (UTC-05:00)Eastern Time(US&Canada) Submit by bethany.georgoulias 9/20/2024 4:09:52 PM (Contact Changes Submitted) Contact • - for • • • ONLY) updatesThis form • . . Certificate of NCC191946 Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters) NC Reference No. NCG01-2019-1946 Original NOI No.* 15967 Project information associated with this permit(cannot change): Permittee Listed Organizaiton cannot be changed(new COC required) Marshallberg Voluntary Fire Department, Inc. Project Name Marshallberg Voluntary Fire Department Address 1138 Straits Road,Smyrna, NC County Carteret Latitude 34.7470 Longitude -76.5211 Date COC Issued* 04/01/2024 Prior Rescission Date This field will populate only if COC has already been rescinded.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 Yes Billing Email NEW Billing Email twade5916@gmail.com Billing Telephone No. NEW Billing (252)241-0733 Telephone No. (Optional) Legally Responsible Individual Contact Information REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES! Legally Responsible John Day Individual(Previous) First Name(New)* Rodney Todd Last Name(New)* Wade NEW Legally Reflects any revisions above Responsible Rodney Todd Wade Individual* Permittee Email johnday.nc@gmail.com (Previous) NEW Permittee twade5916@gmail.com Email* Permittee Telephone 252-729-5111 No.(Previous) NEW Permittee (252)241-0733 Telephone No.* Permittee Mailing P.O. Box 6, 0, Marshallberg, NC 28579-9541 Address(Previous) NEW Permittee Street Address Mailing Address* P.O. Box 6 Address Line 2 City State/Province/Region Marshallberg NC Postal/Zip Code Country 28553 us Permittee Street 1138 Straits Road,0,Smyrna, NC 28579- Address(Previous) 9541 NEW Permittee Street Street Address Address* 109 Goose Pond Rd Address Line 2 City State/Province/Region Marshallberg NC Postal/Zip Code Country 28553 us Change Requested Jeffrey Leland Batten(Board of Directors Treasurer)via Modification request by:* submitted 9/17/2024. Include any additional correspondence records in the Repository COC folder. Additional Information for this update to contact information: Addional Explanation (Optional) Date* 09/20/2024