NCC192196_Contact Update Records (Leg Resp Change)_20220517

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 5/17/2022 1:10:40 PM (Contact Changes Submitted)

Certificate of NCC192196
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-2196
Original NOI No.* 16745
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
AV Homes of Raleigh, LLC
Project Name Honeycutt Farm Phase 11
Address 1000 Piney Grove Wilbon Road, Town of Holly Springs, NC
County Wake
Latitude 35.6242
Longitude-78.8453
Date COC Issued * 10/08/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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. [phone]
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Jeremy Medlin
Individual (Previous)
First Name (New)* Christian
Last Name (New)* Sheppard
NEW Legally Reflects any revisions above
Responsible Christian Sheppard
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 15501 Weston Parkway, Suite 100, Cary, NC
Address (Previous) 27513
NEW Permittee Street Address
Mailing Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Permittee Street 15501 Weston Parkway, Suite 100, Cary, NC
Address (Previous) 27513
NEW Permittee Street Street Address
Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Change Requested N/A - This is a correction (previous revision did not update the name of the legally
by: * responsible person along with the other info.) Jeremy Medlin has now been changed
to Christian Sheppard.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation Correction to legally responsible individual name only.
(Optional)
Date * 05/17/2022

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 5/17/2022 1:00:33 PM (Contact Changes Submitted)

Certificate of NCC192196
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-2196
Original NOI No.* 16745
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
AV Homes of Raleigh, LLC
Project Name Honeycutt Farm Phase 11
Address 1000 Piney Grove Wilbon Road, Town of Holly Springs, NC
County Wake
Latitude 35.6242
Longitude-78.8453
Date COC Issued * 10/08/2019
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? U No
Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Jeremy Medlin
Individual (Previous)
First Name (New)* Jeremy
Last Name (New)* Medlin

NEW Legally Reflects any revisions above
Responsible Jeremy Medlin
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 15501 Weston Parkway, Suite 100, Cary, NC
Address (Previous) 27513
NEW Permittee Street Address
Mailing Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Permittee Street 15501 Weston Parkway, Suite 100, Cary, NC
Address (Previous) 27513
NEW Permittee Street Street Address
Address* 15501 Weston Parkway
Address Line 2
Suite 100
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27513
us
Change Requested Christian Sheppard via Modification request submitted 5/12/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 05/17/2022