NCC192975_Contact Update Record_20201215

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany 12/15/2020 7:30:29 AM (Contact Changes Submitted)

•
Certificate of NCC192975
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-2975
Original NOI No.* 18932
Project information associated with this permit (cannot change):
Permittee Listed
Organizaiton cannot be changed (new CDC required)
SPK Real Property Holdings, LLC
Project Name
Coastal KIA
Address
6103 Market Street, Wilmington, NC
County
New Hanover
Latitude
34.2546
Longitude
-77.8517
Date COC Issued*
01/21/2020
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Which Contacts
f Billing Only
Have Changed?*
r Legally Responsible Individual Only
f Site Contact Only
r BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
F No
r Yes
Billing Email
Billing Telephone
No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Patrick Koballa
Individual
(Previous)
First Name (New)* Patrick
Last Name (New) * Koballa

NEW Legally Peflects any revisions above
Responsible Patrick Koballa
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 910-262-5150
Telephone No.
(Previous)
NEW Permittee 910-262-5150
Telephone No.*
Permittee Mailing 6103 Market Street, 0, Wilmington, NC
Address (Previous) 28405
NEW Permittee
Mailing Address*
Street Address
6103 Market Street
Address Line 2
City
Wilmington
Fbstal / Zip Code
28405
Permittee Street 6103 Market Street, 0, Wilmington, NC
Address (Previous) 28405
NEW Permittee Street Address
Street Address* 6103 Market Street
Address Line 2
city
Wilmington
Fbstal / Zip Code
28405
State / Rovince / Fbgion
NC
Country
US
State / Fkovince / Region
NC
Country
US
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Patrick Koballa
(Previous)
Site Contact Title Owner
(Previous)
Organization
SPK Real Property Holdings, LLC
(Previous)
First Name (New)*
Patrick
Last Name (New) *
Koballa
NEW Site Contact*
Reflects any revisions above
Patrick Koballa

NEW Site Contact Owner
Title
NEW Organization SPK Real Property Holdings, LLC
This field is not required on the NOI form and nay not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 910-262-5150
Telephone No.
(Previous)
NEW Site Contact 910-262-5150
Telephone No.*
Site Contact Mailing 6103 Market Street, 0, Wilmington, NC
Address (Previous) 28405
NEW Site Contact
Mailing Address*
Street Address
6103 Market Street
Address Line 2
City
Wilmington
Fbstal / Zip Code
28405
State / Rovince / Fbgion
NC
Country
us
Change Requested Kemp Roberts via email on 12/15.
by: * Include any additional correspondence records in the Fbpository 00Cfolder.
Additional Information for this update to contact information:
Addional Legally responsible person and site contact are still the same; only email
Explanation addresses needed revision.
(Optional)
Date * 12/15/2020