NCC191505_Contact Update Record_20210914

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Selkane, Aziza 9/14/2021 3:48:00 PM (Contact Changes Submitted)

Certificate of NCC191505
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-1505
Original NOI No.* 15087
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Revere at Mooresville, LLC
Project Name
Revere at Mooresville
Address
269 Talbert Road, Mooresville, NC
County
Iredell
Latitude
35.5889
Longitude
-80.8482
Date COC Issued*
08/26/2019
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This field will populate only if COChas already been rescinded.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
f 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 440 237 1681
Telephone No. (Cptional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Aaron Gross
Individual
(Previous)

First Name (New)* Aaron
Last Name (New) * Gross
NEW Legally Peflects any revisions above
Responsible Aaron Gross
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 440-237-1681
Telephone No.
(Previous)
NEW Permittee 440-237-1681
Telephone No.*
Permittee Mailing 14300 Ridge Road, 0, North Royalton, OH
Address (Previous) 44133
NEW Permittee
Mailing Address*
Street Address
14300 Ridge Road
Address Line 2
City
North Royalton
Fbstal / Zip Code
44133
Permittee Street 14300 Ridge Road, 0, North Royalton, OH
Address (Previous) 44133
NEW Permittee Street Address
Street Address* 14300 Ridge Road
Address Line 2
city
North Royalton
Fbstal / Zip Code
44133
State / Rovince / Fbgion
OH
Country
US
State / F rovince / Region
OH
Country
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Dave Gerdeman
(Previous)
Site Contact Title Project Manager Carolinas
(Previous)
Organization Revere at Mooresville
(Previous)
First Name (New)* Dave

Last Name (New) * Gerdeman
NEW Site Contact* Fbflects any revisions above
Dave Gerdeman
NEW Site Contact Project Manager Carolinas
Title
NEW Organization Revere at Mooresville
This field is not required on the NDI form and nay not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 803-341-2191
Telephone No.
(Previous)
NEW Site Contact 803-341-2191
Telephone No.*
Site Contact Mailing 260 North Revere Cove, 0, Tega Cay, SC
Address (Previous) 29708
NEW Site Contact
Mailing Address*
Street Address
260 North Revere Cove
Address Line 2
City
Tega Cay
Fbstal / Zip Code
29708
State / Rovince / F;bgion
SC
Country
us
Change Requested Email on 9/14/2021 from Rozi Marsh
by: * Include any additional correspondence records in the Pepository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 09/14/2021