NCC205494_Contact Update Record (Email and Site Contact)_20221114

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 11/14/2022 11:59:59 AM (Contact Changes Submitted)

Certificate of NCC205494
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-5494
Original NOI No.* 37363
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Shoreline Baptist Church
Project Name Shoreline Baptist Church
Address 4198 Vanessa Drive, Oak Island, NC
County Brunswick
Latitude 33.9290
Longitude-78.0620
Date COC Issued * 12/23/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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 Woodrow Taylor
Individual (Previous)
First Name (New)* Woodrow
Last Name (New) * Taylor

NEW Legally Reflects any revisions above
Responsible Woodrow Taylor
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 4198 Vanessa Drive Southeast, 0, Southport,
Address (Previous) NC 28461-9031
NEW Permittee Street Address
Mailing Address* 4198 Vanessa Drive Southeast
Address Line 2
City
State / Province / Region
Southport
NC
Postal / Zip Code
Country
28461-9031
us
Permittee Street 4198 Vanessa Drive Southeast, 0, Southport,
Address (Previous) NC 28461-9031
NEW Permittee Street Street Address
Address* 4198 Vanessa Drive Southeast
Address Line 2
City
State / Province / Region
Southport
NC
Postal / Zip Code
Country
28461-9031
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Danny Mathews
(Previous)
Site Contact Title Previous Pastor / Construction Supervisor
(Previous)
Organization Past Pastor / Construction Supervisor (No Org.)
(Previous)
First Name (New)*
David
Last Name (New)*
Bodenheimer
NEW Site Contact*
Reflects any revisions above
David Bodenheimer

NEW Site Contact
Title
NEW Organization 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 336-706-2575
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 4198 Vanessa Drive Southeast, 0, Southport,
Address (Previous) NC 28461-9031
NEW Site Contact Street Address
Mailing Address* 4198 Vanessa Drive Southeast
Address Line 2
City
State / Province / Region
Southport
NC
Postal / Zip Code
Country
28461-9031
us
Change Requested David Bodenheimer via e-mail on 11/14/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 11 /14/2022