NCC230176_Contact Update Record (Site Contact)_20230320

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/20/2023 1:19:44 PM (Contact Changes Submitted)

Certificate of NCC230176
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2023-0176
Original NOI No.* 123302
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
LeoTerra Peace Haven, LLC
Project Name South Fork Village - Phase 1
Address S. Peacehaven Road, Winston Salem, NC
County Forsyth
Latitude 36.0627
Longitude-80.3590
Date COC Issued* 01/20/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 336-671-1858
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Christopher Lyons
Individual (Previous)
First Name (New)* Christopher
Last Name (New) * Lyons

NEW Legally Reflects any revisions above
Responsible Christopher Lyons
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 110-A Shields Park Drive, 0, Kernersville, NC
Address (Previous) 27284
NEW Permittee Street Address
Mailing Address* 110-A Shields Park Drive
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
us
Permittee Street 110-A Shields Park Drive, 0, Kernersville, NC
Address (Previous) 27284
NEW Permittee Street Street Address
Address * 110-A Shields Park Drive
Address Line 2
City State / Province / Region
Kernersville NC
Postal / Zip Code Country
27284 us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Kat Lyons
(Previous)
Site Contact Title Senior Director of Field Operations
(Previous)
Organization LeoTerra Development
(Previous)
First Name (New)* Kat
Last Name (New) * Lyons
NEW Site Contact* Reflects any revisions above
Kat Lyons

NEW Site Contact Senior Director of Field Operations
Title
NEW Organization LeoTerra Development Inc.
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 336-682-1414
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 110-A Shields Park Drive, 0, Kernersville, NC
Address (Previous) 27284
NEW Site Contact Street Address
Mailing Address* 110-A Shields Park Drive
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
us
Change Requested Jason Cheek via email requesting site contact updates on 3/10/2023. Site contact
by: * was already current but was also designated as billing contact with this update.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/20/2023