NCC233177_Contact Update Record (Email Update)_20241015

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 10/15/2024 5:11:02 PM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC233177
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-3177
Original NOI No.* 165083
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
HR Northlake
Project Name Holding Village—Pavilion Building
Address 1498 South Franklin Street,Wake Forest, NC
County Wake
Latitude 35.9588
Longitude -78.5081
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.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. 919-706-9397
NEW Billing [phone]
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Scott Lay
Individual(Previous)
First Name(New)* Scott
Last Name(New)* Lay

NEW Legally Reflects any revisions above
Responsible Scott Lay
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 8480 Honeycutt Road Suite 200,0, Raleigh,
Address(Previous) NC 27615
NEW Permittee Street Address
Mailing Address* 8480 Honeycutt Road Suite 200
Address Line 2
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27615 us
Permittee Street 8480 Honeycutt Road Suite 200,0, Raleigh,
Address(Previous) NC 27615
NEW Permittee Street Street Address
Address* 8480 Honeycutt Road Suite 200
Address Line 2
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27615 us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Scott Lay
(Previous)
Site Contact Title Senior Vice President
(Previous)
Organization Reader Communities
(Previous)
First Name(New)* Scott
Last Name(New)* Lay
NEW Site Contact* Reflects any revisions above
Scott Lay

NEW Site Contact Senior Vice President
Title
NEW Organization Reader Communities
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 919-706-9397
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 8480 Honeycutt Road Suite 200,0, Raleigh,
Address(Previous) NC 27615
NEW Site Contact Street Address
Mailing Address* 8480 Honeycutt Road Suite 200
Address Line 2
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27615 us
Change Requested Scott Lay via e-mail on 10/15/2024(email 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* 10/15/2024