NCC205190_Annual Fee Payment Record_20221202

Action History (UTC-05:00) Eastern Time (US & Canada)
by Workflow 10/30/2022 1:21:58 PM (Workflow Start Event)
Submit by Holloman, Tevye L 12/2/2022 9:46:42 AM (2022 Annual Fee Payment Verification for NCC205190-2022)
0 Matt Oates
Holloman, Tevye L assigned the task to Holloman, Tevye L 12/2/2022 9:46 AM
• The task was assigned to DEMLR NCG01 Annual Fee Team. The due date is: December 12, 2022 5:00
PM 10/30/2022 1:22 PM

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Certificate of NCC205190
Coverage (COC) No. * This is passed from the workflow when the invoice is filed.
NC Reference COC NCG01-2020-5190
No. *
Permit Status: Active
Year COC Issued 2020
This field will be hidden.
Check previous years for outstanding fees (years that do not apply will be blank):
2020 Fee Status
2021 Fee Status PAID
Project Name* Union West Center Medical Facility
Project Address* 6040 W Hwy 74, Indian Trail, NC
Permittee* Benderson Development Company, LLC
County Union
Invoice No.* NCC205190-2022
This is passed from the workflow when the invoice is filed.
Annual Fee* $ 100.00
Invoice Date* 11/1/2022
This is passed from the workflow when the invoice is filed.
Invoice Due Date* 12/1/2022
This is passed from the workflow when the invoice is filed.
An automated email reminder is sent to the permittee when the invoice is due. Wait until invoice is 15 days overdue
before proceeding to a Notice of Deficiency.
Days Overdue 1
Wait at least 15 days until proceeding to NOD.
Important: If you change the choice below to Payment NOT RECEIVED, the fee status becomes PAST DUE, and the
permittee will receive a Notice of Deficiency.
Annual Fee Payment • Fee Payment Received or Not Applicable.
Received* Fee Payment NOT RECEIVED.
Date Payment 12/2/2022
Received * Or, if WAIVED or NOT RECEIVED, this is the date that status is recorded.

Method of Payment* electronic
check
other
ePayment 664871870
Transaction Number*
Fee Status* PAID
Legally Responsible Corporation Service Company Corporation Service Company
Person (Orig.)
Original Permittee E- [e-mail]
mail *
CONFIRM Permittee [e-mail]
E-mail* Opportunity to modify problem e-mail address or permittee contact info
Original Site Contact [e-mail]
E-mail *
CONFIRM Site [e-mail]
Contact E-mail* Opportunity to correct problem e-mail address or site contact info
Original Billing E-mail (if available)
CONFIRM Billing E- Opportunity to correct problem e-mail address or billing contact info
mail
Billing Telephone No.
Permittee Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow).
Site Contact Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow)
Billing Contact Email
This is the email for the 30-day reminder if needed (passed from workflow).
for 30-day Reminder
Project Name for 30-
Union West Center Medical Facility
day Reminder
The project name is passed from workflow for the 30-day reminder
Permittee Name for
Benderson Development Company, LLC
30-day Reminder
The permittee is passed from workflow for the 30-day reminder
County for 30-day
Union
Reminder
The county is passed from workflow for the 30-day reminder
Additional Billing Contact E-mails
Additional E-mail for
CC:
Review Date * 12/2/2022