NCC202816_Contact Update Record_20210729

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 7/29/2021 11:31:54 AM (Contact Changes Submitted)

Certificate of NCC202816
Coverage (COC) Enter the Certificate of Coverage Nmber (Use capital letters)
No.*
NC Reference No. NCG01-2020-2816
Original NOI No.* 27702
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new OOC required)
MCB Camp Lejeune
Project Name
Ambulatory Care Center/Dental Clinic Replacement P-9838-MCAS New River
Address
Canal Street, Camp LeJuene, NC
County
Onslow
Latitude
34.7168
Longitude
-77.4543
Date COC Issued*
08/18/2020
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Which Contacts
f Billing Only
Have Changed?*
r Legally Responsible Individual Only
r Site Contact Only
r BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
r No
r Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone
No.
NEW Billing 910-451-3238 x3242
Telephone No. (Cptional)
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Bill Jones
(Previous)

Site Contact Title Superintendent
(Previous)
Organization DeMaria Building Company,lnc
(Previous)
First Name (New)*
Jeff
Last Name (New) *
Burch
NEW Site Contact*
Reflects any revisions above
Jeff Burch
NEW Site Contact
Superintendent
Title
NEW Organization DeMaria Building Company, Inc
This field is not required on the N01 form and nay not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email *
Site Contact
9107519911
Telephone No.
(Previous)
NEW Site Contact
[phone]
Telephone No.*
Site Contact Mailing
450 Grand River Avenue, 0, Novi, MI 48374-
Address (Previous)
1305
NEW Site Contact Street Address
Mailing Address* 45500 Grand River Avenue
Address Line 2
aty
State / Frovince / Region
Novi
MI
Fbstal / Zip Code
Country
48374
U.S.A
Change Requested Darin Parlier Wth DeMaria via email on 7/29/2021.
by: * Include any additional correspondence records in the Repository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 07/29/2021