NCC204278_Contact Update Record (Email Correction)_20221017

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 10/17/2022 1:31:58 PM (Contact Changes Submitted)

Certificate of NCC204278
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-4278
Original NOI No.* 32001
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
PB Pembroke Owner, LLC
Project Name Pembroke Student Housing, Phase 1
Address 696 Prospect Road, Pembroke, NC
County Robeson
Latitude 34.6946
Longitude-79.1978
Date COC Issued * 09/29/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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? U No
Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing 601-506-5026
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Timothy McCarty
Individual (Previous)
First Name (New)* Timothy
Last Name (New) * McCarty

NEW Legally Reflects any revisions above
Responsible Timothy McCarty
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee 601-506-5026
Telephone No.*
Permittee Mailing 1888 Main Street, Suite C163, 0, Madison,
Address (Previous) MS 27615
NEW Permittee Street Address
Mailing Address* 1888 Main Street, Suite C163
Address Line 2
City
Madison
Postal / Zip Code
27615
State / Province / Region
MS
Country
USA
Permittee Street 160 Mine Lake Ct, Suite 200, 0, Raleigh, NC
Address (Previous) 27615
NEW Permittee Street Street Address
Address* 160 Mine Lake Ct, Suite 200
Address Line 2
City State / Province / Region
Raleigh NC
Postal / Zip Code Country
27615 USA
Change Requested Bo Wigley (Site Contact) via email on 10/17/2022. Correction to email address only.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 10/17/2022