NCC200907_Contact Update Record_20210310

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 3/10/2021 2:02:46 PM (Contact Changes Submitted)

•
Certificate of NCC200907
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2020-0907
Original NOI No.* 22757
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new CDC required)
Circle Up LLC
Project Name
The Retreat at Pittsboro
Address
196 Chatham Business Drive, Pittsboro, NC
County
Chatham
Latitude
35.7171
Longitude
-79.1627
Date COC Issued*
03/16/2020
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This field will populate only if COChas already been rescinded.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 Richard Angino
Individual
(Previous)
First Name (New)* Richard
Last Name (New) * Angino

NEW Legally Fbflects any revisions above
Responsible Richard Angino
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 336-499-1963
Telephone No.
(Previous)
NEW Permittee 336-499-1963
Telephone No.*
Permittee Mailing 463 1/2 Carolina Circle, 0, Winston Salem,
Address (Previous) NC 27104
NEW Permittee
Mailing Address*
Street Address
463 1/2 Carolina Circle
Address Line 2
City
Winston Salem
Fbstal / Zip Code
27104
Permittee Street 463 1/2 Carolina Circle, 0, Winston Salem,
Address (Previous) NC 27104
NEW Permittee Street Address
Street Address* 463 1/2 Carolina Circle
Address Line 2
city
Winston Salem
Fbstal / Zip Code
27104
State / Rovince / Fbgion
NC
Country
USA
State / Rovince / Faegion
NC
Country
USA
Change Requested Wil Warren
by: * Include any additional correspondence records in the %pository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 03/10/2021