NCC213022_Contact Update Record (Legally Resp Change)_20230508

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 5/8/2023 7:09:37 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC213022
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-3022
Original NOI No.* 53055
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Person County
Project Name North Park
Address North Park Dr., Roxboro, NC
County Person
Latitude 36.4505
Longitude -78.9483
Date COC Issued* 05/19/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
* Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 3365831033
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Heidi York
Individual(Previous)
First Name(New)* Katherine
Last Name(New)* Cathey

NEW Legally Reflects any revisions above
Responsible Katherine Cathey
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 304 S Morgan St,2nd Floor Mailroom,
Address(Previous) Roxboro, NC 27573
NEW Permittee Street Address
Mailing Address* 304 S Morgan St
Address Line 2
Room 212
City State/Province/Region
Roxboro NC
Postal/Zip Code Country
27573 us
Permittee Street 304 S Morgan St,2nd Floor Mailroom,
Address(Previous) Roxboro, NC 27573
NEW Permittee Street Street Address
Address* 304 S Morgan St
Address Line 2
Room 212
City State/Province/Region
Roxboro NC
Postal/Zip Code Country
27573 us
Change Requested Katherine Cathey(County Manager)via Modification request submitted 5/4/2023.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 05/08/2023