NCC213102_Contact Update Record (Site Contact)_20220518

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Selkane, Aziza 5/18/2022 5:52:01 PM (Contact Changes Submitted)

Certificate of NCC213102
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2021-3102
Original NOI No.* 53291
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
TWP PCP Mocks Retail, LLC
Project Name HWY 55
Address Yadkinville Road, Mocksville, NC
County Davie
Latitude 35.9159
Longitude-80.5829
Date COC Issued * 05/25/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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? • No
Yes
Billing Email [e-mail]
Billing Telephone No. 404-913-9131
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Kirby Cordell
(Previous)
Site Contact Title General Contractor
(Previous)
Organization KC Construction
(Previous)
First Name (New)* Michael

Last Name (New)* Shultz
NEW Site Contact* Reflects any revisions above
Michael Shultz
NEW Site Contact
Title
NEW Organization Dixon Contracting
This field is not required on the NOI form and may not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 606-875-5049
Telephone No.
(Previous)
NEW Site Contact 919-819-6022
Telephone No.*
Site Contact Mailing 360 Sweetwater Church Road, 0,
Address (Previous) Douglasville, GA 30134-5510
NEW Site Contact Street Address
Mailing Address* 4801 Glenwood Ave.
Address Line 2
Ste 200
City
State / Province / Region
Raleigh
NC
Postal / Zip Code
Country
27612
us
Change Requested Alex Ostendorf on 5/15/2022 by email. Matt Widmaier, the Legally Responsible
by: * Person, was cc-ied on the email too.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 05/18/2022