NCC205162_Contact Update Record (Legally Resp Change)_20221214

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 12/14/2022 8:31:41 AM (Contact Changes Submitted)

Certificate of NCC205162
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-5162
Original NOI No.* 35368
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
LG APT NC Charlotte Northlake LP
Project Name Affordable Suites Hotel - Statesville Rd
Address 9655 Statesville Rd, Charlotte, NC
County Mecklenburg
Latitude 35.3544
Longitude-80.8411
Date COC Issued * 12/03/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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 [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Don Keum
Individual (Previous)
First Name (New)* Bruce
Last Name (New) * Collins

NEW Legally Reflects any revisions above
Responsible Bruce Collins
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 10801 Monroe Rd, Suite C, Matthews, NC
Address (Previous) 28105-8336
NEW Permittee Street Address
Mailing Address* 10801 Monroe Rd
Address Line 2
Suite 200
City
State / Province / Region
Matthews
NC
Postal / Zip Code
Country
28105
us
Permittee Street 10801 Monroe Rd, Suite C, Matthews, NC
Address (Previous) 28105-8336
NEW Permittee Street Street Address
Address* 9655 Statesville Road
Address Line 2
City State / Province / Region
Charlotte NC
Postal / Zip Code Country
28269 us
Change Requested Latwanna Jenkins via e-mail on 12/12/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 12/14/2022