NCC200434_Contact Update Record_20210210 (2)

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 2/10/2021 4:31:07 PM (Contact Changes Submitted)

•
Certificate of NCC200434
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2020-0434
Original NOI No.* 21457
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new CDC required)
Suzanne Pegler
Project Name
PAR Estates (#403447)
Address
13712 Huntersville-Concord Road, Huntersville, NC
County
Mecklenburg
Latitude
35.4120
Longitude
-80.8115
Date COC Issued*
02/04/2020
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This field will populate only if COChas already been rescinded.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 Suzanne Pegler
Individual
(Previous)
First Name (New)* Suzanne
Last Name (New) * Pegler

NEW Legally Peflects any revisions above
Responsible Suzanne Pegler
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 3363019014
Telephone No.
(Previous)
NEW Permittee 3363019014
Telephone No.*
Permittee Mailing 14037, 0, Huntersville, NC 28078
Address (Previous)
NEW Permittee Street Address
Mailing Address* 14037 Lawther Road
Address Line 2
City
State / Rovince / Fbgion
Huntersville
NC
Fbstal / Zip Code
Country
28078
us
Permittee Street 14037 Lawther Road, 0, Huntersville, NC
Address (Previous) 28078
NEW Permittee Street Address
Street Address* 14037 Lawther Road
Address Line 2
City
State / Fkovince / Region
Huntersville
NC
Fbstal / Zip Code
Country
28078
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact
Suzanne Pegler
(Previous)
Site Contact Title
Owner
(Previous)
Organization
(Previous)
First Name (New)*
Suzanne
Last Name (New) *
Pegler
NEW Site Contact*
Reflects any revisions above
Suzanne Pegler

NEW Site Contact Owner
Title
NEW Organization This field is not required on the N01 form and may not pre -populate
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact
3366019014
Telephone No.
(Previous)
NEW Site Contact
3366019014
Telephone No.*
Site Contact Mailing
14037 Lawther Road, 0, Huntersville, NC
Address (Previous)
28078
NEW Site Contact
Mailing Address*
Street Address
14037 Lawther Road
Address Line 2
Cty
Huntersville
Fbstal / Zip Code
28078
State / Rovince / Fbgion
NC
Country
us
Change Requested Suzanne Pegler
by: * Include any additional correspondence records in the Fbpository 00Cfolder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date *
02/10/2021