NCC215888_Contact Update Record (Legally Resp Change)_20221017

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 10/17/2022 8:32:33 AM (Contact Changes Submitted)

Certificate of NCC215888
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2021-5888
Original NOI No.* 69253
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Smith Douglas Homes
Project Name Orchard Creek
Address 9431 Plaza Rd Extension, Charlotte, NC
County Mecklenburg
Latitude 35.2548
Longitude-80.7038
Date COC Issued * 10/25/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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
[e-mail]
NEW Billing Email
[e-mail]
Billing Telephone No.
9198685391
NEW Billing
[phone]
Telephone No.
(Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible James Gaskins
Individual (Previous)
First Name (New)* John
Last Name (New)* Brunner

NEW Legally Reflects any revisions above
Responsible John Brunner
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing P.O. Box 311, 0, Midland, NC 28107
Address (Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 311
Address Line 2
City
Midland
Postal / Zip Code
28107
State / Province / Region
NC
Country
United States
Permittee Street 4297 NC Highway 24/27 E, Suite B, Midland,
Address (Previous) NC 28107
NEW Permittee Street Street Address
Address* 4297 NC Highway 24/27 E
Address Line 2
Suite B
City State / Province / Region
Midland NC
Postal / Zip Code Country
28107 United States
Change Requested John Brunner via Modification request submitted 10/10/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 10/17/2022