NCC231058_Contact Update Record (Emails Only)_20230501

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 5/1/2023 4:13:44 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC231058
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-1058
Original NOI No.* 136166
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
WEIDL PROPERTIES,LLC
Project Name STRATFORD HEIGHTS
Address SANDIA AVENUE,WINSTON SALEM, NC
County Forsyth
Latitude 36.0636
Longitude -80.3264
Date COC Issued* 04/28/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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. 336-577-7775
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible ROBERT WEIDL
Individual(Previous)
First Name(New)* ROBERT
Last Name(New)* WEIDL

NEW Legally Reflects any revisions above
Responsible ROBERT WEIDL
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 2806 REYNOLDA RD,#172,WINSTON
Address(Previous) SALEM, NC 27106
NEW Permittee Street Address
Mailing Address* 2806 REYNOLDA RD
Address Line 2
#172
City State/Province/Region
WINSTON SALEM NC
Postal/Zip Code Country
27106 FORSYTH
Permittee Street 2806 REYNOLDA RD,#172,WINSTON
Address(Previous) SALEM, NC 27106
NEW Permittee Street Street Address
Address* 2806 REYNOLDA RD
Address Line 2
#172
City State/Province/Region
WINSTON SALEM NC
Postal/Zip Code Country
27106 FORSYTH
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact ROBERT WEIDL
(Previous)
Site Contact Title MEMBER MANGER
(Previous)
Organization WEIDL PROPERTIES,LLC
(Previous)
First Name(New)* ROBERT
Last Name(New)* WEIDL

NEW Site Contact* Reflects any revisions above
ROBERT WEIDL
NEW Site Contact MEMBER MANGER
Title
NEW Organization WEIDL PROPERTIES,LLC
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 336-577-7775
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 2806 REYNOLDA RD,#172,WINSTON
Address(Previous) SALEM, NC 27106
NEW Site Contact Street Address
Mailing Address* 2806 REYNOLDA RD
Address Line 2
#172
City State/Province/Region
WINSTON SALEM NC
Postal/Zip Code Country
27106 FORSYTH
Change Requested Robert Weidl via email on 5/1/2023(email addresses revised to lower case letters).
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 05/01/2023