NCC216317_Contact Update Record (Address Only)_20221103

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 11/3/2022 10:37:20 AM (Contact Changes Submitted)

Certificate of NCC216317
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2021-6317
Original NOI No.* 72868
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Sandeep Uthra
Project Name Twin Lakes Subdivision
Address Sugar Maple Ln, Matthews, NC
County Union
Latitude 35.0226
Longitude-80.7010
Date COC Issued* 11/12/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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. 704-244-1299
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Sandeep Uthra
Individual (Previous)
First Name (New) *
Sandeep
Last Name (New)*
Uthra
NEW Legally
Reflects any revisions above
Responsible
Sandeep Uthra
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee 704-244-1299
Telephone No.*
Permittee Mailing 4824 Summer Hill Way, 0, Winston-Salem,
Address (Previous) NC 27106
NEW Permittee Street Address
Mailing Address* 12430 Park Potomac Ave
Address Line 2
Unit N450
City State / Province / Region
Potomac MD
Postal / Zip Code Country
20854 United States
Permittee Street 4824 Summer Hill Way, 0, Winston-Salem,
Address (Previous) NC 27106
NEW Permittee Street Street Address
Address* 12430 Park Potomac Ave
Address Line 2
Unit N450
City State / Province / Region
Potomac MD
Postal / Zip Code Country
20854 United States
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Sandeep Uthra
(Previous)
Site Contact Title Owner
(Previous)
Organization
(Previous)
First Name (New)* Sandeep
Last Name (New) * Uthra
NEW Site Contact* Reflects any revisions above
Sandeep Uthra
NEW Site Contact Owner
Title

NEW Organization
Site Contact Email
(Previous)
NEW Site Contact
Email*
This field is not required on the NOI form and may not pre -populate.
[e-mail]
[e-mail]
Site Contact 704-244-1299
Telephone No.
(Previous)
NEW Site Contact 704-244-1299
Telephone No.*
Site Contact Mailing 4824 Summer Hill Way, 0, Winston-Salem,
Address (Previous) NC 27106
NEW Site Contact Street Address
Mailing Address* 12430 Park Potomac Ave
Address Line 2
Unit N450
City
Potomac
Postal / Zip Code
20854
State / Province / Region
MD
Country
United States
Change Requested Sandeep Uthra via email on 11/1/2022 (address updates only).
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 11 /03/2022