NCC200205_Contact Update Record_20210120

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 1/20/2021 11:17:17 AM (Contact Changes Submitted)

•
Certificate of NCC200205
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2020-0205
Original NOI No.* 20674
Project information associated with this permit (cannot change):
Permittee Listed
Organizaiton cannot be changed (new CDC required)
Sampson Construction Co., Inc.
Project Name
Dormie Club - Phase 1 Cottages
Address
Beulah Hill Church Rd., West End, NC
County
Moore
Latitude
35.2622
Longitude
-79.5060
Date COC Issued*
01/17/2020
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This field will populate only if COChas already been rescinded.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
f 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 Justin Hall
Individual
(Previous)
First Name (New)* Justin
Last Name (New) * Hall

NEW Legally Fbflects any revisions above
Responsible Justin Hall
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 402-416-6569
Telephone No.
(Previous)
NEW Permittee 402-416-6569
Telephone No.*
Permittee Mailing 3730 South 14th Street, 0, Lincoln, NE
Address (Previous) 68502
NEW Permittee
Mailing Address*
Street Address
5825 S.
Address Line 2
14th St
City
Lincoln
Fbstal / Zip Code
68512
Permittee Street 3730 South 14th Street, 0, Lincoln, NE
Address (Previous) 68502
NEW Permittee Street Address
Street Address* 5825 S.
Address Line 2
14th St
city
Lincoln
Fbstal / Zip Code
68512
State / Rovince / Fbgion
NE
Country
us
State / Rovince / Faegion
NE
Country
us
Change Requested Lisa Holle
by: * Include any additional correspondence records in the %pository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 01 /20/2021