NCC221238_Contact Update Record (Email and Name Correction)_20230331

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 3/31/2023 11:08:18 AM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC221238
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2022-1238
Original NOI No.* 85098
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
City of Fayetteville
Project Name Fire Station 4
Address Bragg Boulevard(NC-24),City of Fayetteville, NC
County Cumberland
Latitude 35.0833
Longitude -78.9460
Date COC Issued* 04/21/2022
Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
4) Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 910-433-1990
NEW Billing [phone]
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Douglas Hewitt
Individual(Previous)
First Name(New)* Douglas
Last Name(New)* Hewett

NEW Legally Reflects any revisions above
Responsible Douglas Hewett
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 433 Hay Street,0, Fayetteville, NC 28301-
Address(Previous) 0007
NEW Permittee Street Address
Mailing Address* 433 Hay Street
Address Line 2
City State/Province/Region
Fayetteville NC
Postal/Zip Code Country
28301-0007 USA
Permittee Street 433 Hay Street,0, Fayetteville, NC 28301-
Address(Previous) 0007
NEW Permittee Street Street Address
Address* 433 Hay Street
Address Line 2
City State/Province/Region
Fayetteville NC
Postal/Zip Code Country
28301-0007 USA
Change Requested Jason Miles(site contact)via email on 3/31/2023(email address and last name
by:* spelling correction).
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 03/31/2023