NCC230767_Contact Update Record_20240311

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 3/11/2024 8:55:35 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC230767
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-0767
Original NOI No.* 132120
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Town of Morrisville
Project Name Church Street Park Southern Lot
Address 905 Church Street, Morrisville, NC
County Wake
Latitude 35.8400
Longitude -78.8400
Date COC Issued* 03/21/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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? 0• No
0 Yes
Billing Email [e-mail]
Billing Telephone No. 9194637113
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Martha Paige
Individual(Previous)
First Name(New)* Brandon
Last Name(New)* Zuidema
NEW Legally Reflects any revisions above
Responsible Brandon Zuidema
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 100 Town Hall Drive,0, Morrisville, NC
Address(Previous) 27560-8147
NEW Permittee Street Address
Mailing Address* 100 Town Hall Drive
Address Line 2
City State/Province/Region
Morrisville NC
Postal/Zip Code Country
27560-8147 us
Permittee Street 100 Town Hall Drive,0, Morrisville, NC
Address(Previous) 27560-8147
NEW Permittee Street Street Address
Address* 100 Town Hall Drive
Address Line 2
City State/Province/Region
Morrisville NC
Postal/Zip Code Country
27560-8147 us
Change Requested Brandon Zuidema via Modification request submitted 3/6/2024.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 03/11/2024