NCC215453_Contact Update Record (Address Only)_20231019

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 10/19/2023 8:01:10 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC215453
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-5453
Original NOI No.* 66855
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Longwood Village, LLC
Project Name Longwood Village
Address 1138 Lewisville-Clemmons Road, Lewisville, NC
County Forsyth
Latitude 36.0817
Longitude -80.3933
Date COC Issued* 09/30/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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? 0• No
0 Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Ron Davis
Individual(Previous)
First Name(New)* Ron
Last Name(New)* Davis
NEW Legally Reflects any revisions above
Responsible Ron Davis
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 609,0, Lewisville, NC 27023-9635
Address(Previous)
NEW Permittee Street Address
Mailing Address* 380H Knollwood Street
Address Line 2
#253
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27103 US
Permittee Street 1310 Lewisville Clemmons Road, 0,
Address(Previous) Lewisville, NC 27023-9635
NEW Permittee Street Street Address
Address* 380H Knollwood Street
Address Line 2
#253
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27103 US
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Ron Davis
(Previous)
Site Contact Title Manager
(Previous)
Organization Longwood Village, LLC
(Previous)
First Name(New)* Ron
Last Name(New)* Davis
NEW Site Contact* Reflects any revisions above
Ron Davis
NEW Site Contact Manager
Title

NEW Organization Longwood Village, 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 [phone]
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing P.O. Box 609,0, Lewisville, NC 27023
Address(Previous)
NEW Site Contact Street Address
Mailing Address* 380H Knollwood Street
Address Line 2
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27103 us
Change Requested Ron Davis via email on 10/18/2023(address updates only).
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 10/19/2023