NCC213883_Contact Update Record (Address Only)_20230803

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 8/3/2023 2:05:19 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC213883
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-3883
Original NOI No.* 57478
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
West Homes of NC,LLC
Project Name Larkin/Fox Den Phase 4
Address 186 Wedge View Way,Statesville, NC
County Iredell
Latitude 35.7431
Longitude -80.8648
Date COC Issued* 07/01/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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. 8042918481
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Earl Dickinson
Individual(Previous)
First Name(New)* Earl
Last Name(New)* Dickinson
NEW Legally Reflects any revisions above
Responsible Earl Dickinson
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 1207 Roseneath Rd,0, Richmond,VA 23226
Address(Previous)
NEW Permittee Street Address
Mailing Address* 4905 Dickens Road
Address Line 2
Suite 201
City State/Province/Region
Richmond VA
Postal/Zip Code Country
23230 USA
Permittee Street 1207 Roseneath Rd,0, Richmond,VA 23226
Address(Previous)
NEW Permittee Street Street Address
Address* 4905 Dickens Road
Address Line 2
Suite 201
City State/Province/Region
Richmond VA
Postal/Zip Code Country
23230 USA
Change Requested Earl Dickinson via e-mail on 8/2/2023(address update only)
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 08/03/2023