BUILDING
Each section below to be filled out by Application # 500
whomever performing work. Must be owner Harnett County Central Permitting
or licensed contractor. Address, company PO Box 65 Lillington, NC 27548
name & phone must match information on Phone 910-893-7525 Fax 910-893-2793 www.harnett.org
license. Application for Building and Trades Permit /
Owner's Name: ~a,, Date: 7 V,7-0,7
Site Address: yz y /Z :r~ nL~ 11'e, 5u~ n_PIhone: QL 5;/ ' 75'-?
Directions to job site from Lillington: /V.,; z/i
41 2IZ4 A~i-' n~raw~ 011 rlnZ-Zf
Subdivision: /I u Lot:
Construction Type: (Please Check) Building Use: (Please Check)
- New - Moved House -pesidential _ Commercial
Renovation - Addition _ Other Modular Multi-Family
t~iS'+1 &T4-
Total Project Cost: Description of Proposed Work: M0 ck - (rckr xa uP5+0i{
Heated SF Unheated SF Finished Rec Room? Crawl Space Slab ( )
General Contractor information Building Cost $
Building Contractor's Company Name Telephone
Address ! JLicense # J~ 1 J
Must sign second page & fill out third page y
ig ature of O ner/Contractor/Officer(s) of Corporation
Electrical Permit Information Elec Cost $
Description of Work Service Size: Amps #TPoles
Electrical Contractor's Company Name Telephone
Address License #
to f Officer(s) of Corporation
Mechanical Permit Information Mach Cost $ J
Description of Work # Units
Mechanical Contractor's Company Name Telephone C7J
a{
Address License se# 'l
o~
Igpatu~9of car(s) of Corporation U
Plumbina Permit Information Plumb Cost $ n (~1
Description of Work # Baths y ~ ~p
Plumbing Contractor's Company Name Telephone 1
Address, License #
nat re,of Offcer(s) of Corporation 1 J
Insulation Permit Information
~~1 t ~S2
Insula ion Contractor's Company Name & Address Telephone
Page 1 of 3 7/07
i
Application #
Affidavit for Worker's Compensation
N.C.G.S.87-14
I
The undersigned applicant for Building Permit # being the:
General Contractor
G Owner
Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), firm(s) or corporation(s) performing
the work set forth in the permit:
Has/have three (3) or more employees and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more subcontractors(s) and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more subcontractors(s) who has/have their own policy of
orkers' compensation insurance covering themselves.
~as/have not more than two (2) employees and no subcontractors.
11
While working on the project for which this permit is sought it is understood that the Central Permitting
Department issuing the permit may require certificates of coverage of worker's compensation
insurance prior to issuance of the permit and at any time during the permitted work from any person,
firm or corporation carrying out the work.
Firm Name:
Sign/Title: ~:t/. /-✓~~i ~t
X Date:
I
I
Page 3 of 3 7/07
►;a
'Each Saction below to be filled out by r Application #
whomever performing work. Must be owner Harnett County Central Permitting
or licensed contractor. Address, company PO Box 65 Lillington, NC 27546
name & phone must match information on Telephone Number 914893-7525 www.hamett.org
license. Application for Building and Trade Permit
Owner'sName:,T04"e.U lA~ht+C _ Date: q-IS-O(o
Address: )(0810 d If-'rt(ar1Kt ILYlC2i~ 1Y. LUl~llLaxl VlUiliMne: qIq-S(o7-2082
Directions to job site from Lillington: 0 I WCf
( n IiAh+ ~J ! lef4 on ColCnsb~vu y Ie + do Iw1I"+ bvt 42.
Suls4m ion:lc+} )n CI0_iASCbY-nerA miles rirnhtG~ f'4 1~c+
J~
Y New T e: (Please Check) Building Use: (Please Check)
New _ Moved House _ Residential Commercial
-Renovation -Addition -Other ylNodular C Multi-Family
Total Project Costs31p3r 000 Description of Proposed Work: (l'rT -6-ar 1e rntoau1a.,r
General Contractor Information
Heated SF 420n Crawl Space O Building Construction Cost $ 3Y4/0Dnct(A atI
Unheated S -Slab ( ) Acres Disturbed i Stories 2- , q vac>;,e.
l /i1~ruJ lAn 16e5 Iw dba Cair~Iink gICl-TX-zLf-)7 V
Building Contractor's Company Name(' -9M (31dir5 Telephone
w 5. r 5X
Xignature License #
of OwnerlContractorlOfficer(s) of Corporation - Must sign back of form & workers comp
Electrical Permit Information
Description of Work OO Electrical Cost $ Jr000.00
TS Pole: Yes No M Underground Overheard ( )
Permanent Service: Underground O Overhead O Service Size: a~00 Amps
f4WkW E_1PGfylc, qlq- y9a-CGq_3
Electrical Contractor's Company Name Telephone
7x03 Broadwau OCI 500666d X27330
Ad`dress 1 License #
Signature of Officer(s) of Corporation
Mechanical Permit Information
Description of Work Af
Number of Units a Type System 121 if tfP Mechanical Cost $10,000.00
n °t F{ WAC Inc • q 19 - "]-7-7-S42b
Mechanical Contractor's Company Name Telephone
L116 W. 6uirden 4.tSan-(DrcA, lk'27-aab a33i1
*dftss, License #
Signature of Officer(s) of Corporation
Plumbin Per it Information
Description of Work
M of Bath Y Plumbing Cost $ 300o.CO
o q Icl-g08-80S4
Plumbing Contractor's Co pany Name Telephone
160 So) ve Lane S ford I\IC2 3a 9
i Address License #
if + -A-0
11 gnature of Officer(s) of Corporation
Insulation Permit Information Reside tial (d Other O Not Required ( )
k tl~ In iJ tin SICI old 1ru S91'e (2 _ I o-~ i-0449
Insulation Contractor's Company Name & Address n,,,- KC Telephone
Page 1 of 3 Z'7 ~'Zc) 8/06
i
i0'd 71101
• Each section below to be film Out by I ~ Application li
whomevar PerfOrminu work. Must be owner Harnett County Central Permitting
or licensed contractor. Addt=. company Pp Box 65 Ullin9tcn, NC 27546
name & phone must match irribmaton on Telephone Number 910-693.7525 www-hamett.org
5e rr Apolicetion for Building and Trade Permit
Owner's Name: P Y' Date: Q'
~ Address:l(D~jo i"t IfP_I tt7«rt ~'(.IUIn.';-1/cwlslf~r,e: Gig{-S(o~-?.0~42..
i ~ a 7sal~
tom. r'
Directions to job site from Lillington: 01 -1
(IIrri,47'',l lish+ P left on Calcasbgvt, .rI, t pn Pia II k4 1 + On ua
SebE♦ivisiomlyt'~11-~~ AV G-tPS •c p f Y1GtA-Y'✓L°.
C st~T e~ (Please Check) Building Use: (Please Check)
New Moved House Residential _ Commercial
_ Renovation _ Addition Other _141odular _Multi-Family
Total Project Cost-3k3 -QOD Description of Proposed work: 0
e42oo General Contractor information
Heated SF Crawl Space Building Construction Cost $ 3 3 lAtGl f tiff
SF Slab O Acres Disturbed 1 Stories z0.afQ
Unheated
y~ Inc ~abil coxzIlruc C'(I4-77(0-247 C3
Building Contractor's Company NarrteL(t~(Ys Telephony
Lu rJ. r J~r3 9
ress license #
~I
ature of f OwnedContractor/Officer(s) of Corporation - Must sign back of farm & workers COMP
IIgn
Ela rice Permit information
Description of Work t3O Electrical Cost $ 5000.Od
TS Pole: Yes O No (4 Underground() Overheard ( )
Permanent Service: Underground Overhead Service Size; ADD Amps
I}rarJclAf -JeCLJc G(a u9a-CGq
Electrical Contractor's Company Name Telephone
7cW3 ~roadwcui d Surd Itk z~33o~ S"7-6
Address //tt license #
Signature of Officer(s) of Corporation
Mechanical Permit Information
Description of Work fr'P
of Units Type Syste Mechanical Cost
Number $ i~ooo.
D-i H WAC Inc. Qn--1-17-9428
Mechanical Contractor's Company Name Telephone
)-415 fA1 • l e4 - r t,4-aa- a 3 3'71
T License #
(""dIIAlitL- !5AES'-n~)
Signatureof Offioer(s o Corporation
Plumbing Permit information
Description of Work s
tuber of Baths 1 Plumbing Cost $ 3aoo.CG
r) g1cl-X08-80IN
Plumbing Contractors C4thpany Name Telephone
160 i S iVe (✓cirie S for~J NrGa a_ a33~8
L tense #
A ress
-Tt~iJ
J
Qgnature of Officer(s) of Corporation
Insulation Permit Informal ionn Residental (d Other Not Required ( )
o q 1 Sr0
re- QC4- - A_ j o- QR9
Insulation Contractors Company Name & Address ►1P,,tr W- Telephone
Page I of 3 Z 7-Z5 8106
LO/10'd b6bZ %6, 6S6 aN0dNlJS,ino'sn0H Aa0i3UzJ ES:60 9002-Orr-d3S
• Application #
Sprinkler System Information - Commercial
Sprinkler Contractor's Company Name Telephone
Contact Person
Address License #
Signature of Officer(s) of Corporation
Fire Alarm System Information - Commercial
Fire Alarm Contractor's Company Name Telephone
Contact Person
Addres License #
Signature of Officer(s) of Corporation
Driveway Access
NC Department of Transportation Driveway Access/Permit? Yes - No _
I hereby certify that I have the authority to make necessary application, that the application is correct
and that the construction will conform to the regulations in the Building, Electrical, Plumbing and
Mechanical codes, and the Harnett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and if any changes occur including listed contractors, site plan,
building and trade plans, Environmental Health permit changes or proposed use changes, I certify it is
my responsibility to notify the Harnett County Central Permitting Department of any and all changes.
`~'k~~a da 9-/9-
Signature of Owner/Contractor/Officer(s) of Corporation Date
it
II
~I
it
I
Page 2 of 3 8/06
Application #
Affidavit for Worker's Compensation
N.C.G.S.87-14
The undersigned applicant for Building Permit # being the:
General Contractor
Owner
T Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), firm(s) or corporation(s) performing
the work set forth in the permit:
Has/have three (3) or more employees and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more subcontractors(s) and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more suboontractors(s) who has/have their own policy of
workers' compensation insurance covering themselves.
Has/have not more than two (2) employees and no subcontractors.
While working on the project for which this permit is sought it is understood that the Central Permitting
Department issuing the permit may require certificates of coverage of worker's compensation
insurance prior to issuance of the permit and at any time during the permitted work from any person,
firm or corporation carrying out the work.
Firm Name:I~L ~-a 1t n U Imo, t J) . a CO)v-r C- L ~ ~ '
Sign/Title: "1 rlll..t.(.CL a Mty- N fi R (t l YA"C 4AI-
Date: t4-12,006
Page 3 of 3 8/06
{ v1:6'91J'LsPOP,.
04
Required Inspections for SFA/SFD Appl # a bb Z
Valuation 2 a~~~ 3d'7)
Sq. Ft
10 R'Bldg Footing 60 Two Trade Final > 2500
10-30 fR•Elec Temp Service Pole 60 One Trade Final
20 ----FfBldg Foundation 60 One Trade Final > 2500
20 ✓Address Confirmation 999 Envir. Operations Permit
30-999 R'Open Floor
30-999 R'Bidg Slab Insp
30-999 R'Elec Under Slab
f ,
30-999 R'Plumb under Slab
30-999 R'Bldg Water/Damp Proofing
40 Four Trade Rough In
40 ✓Four Trade Rough In > 2500
40 Three Trade Rough In
40 Three Trade Rough In > 2500
40 Two Trade Rough In
40 Two Trade Rough In > 2500
40 One Trade Rough In
40 One Trade Rough In > 25-070
50 R'Insulation Inspection `
60 Four Trade Final
60 ✓ Four Trade Final > 2500
60 Three Trade Final
60 Three Trade Final > 2500
60 Two Trade Final
NORTH CAROLINA MODULAR BUILDING
SET-UP CONTRACTOR LICENSE BOND
Bond Number N 1096
WE,
Quail Run Homes Inc dba Carolina Custom B tilt rc as principal, located at
3239 Hwy- 87 Cnnth- Sanford , NC 27330
and Merchants Bonding o ny (Surety) of 2100 Fleur Ave Dee Moines A 50312 (address) a
corporation incorporated under the laws of the State of Iowa and duly licensed to transact a surety
business in the State of North Carolina as surety, are indebted and bound to the Harnett County. NC
inspection department in the sum of five thousand ($5,000) dollars for which payment we bind ourselves
and our legal representatives jointly and severally.
THE CONDITION OF THIS OBLIGATION IS SUCH, that whereas the principal has entered into a
contract for the set-up and installation of the modular building described herein;
NOW, THEREFORE, if the principal and all his agents and employees shall set-up and install said
modular building in compliance with the regulations of the North Carolina State Building Code
governing installation of modular buildings, then this obligation shall be null and void; otherwise, it
shall be in full force and effect.
It is expressly provided that:
1. This bond is executed by the said principal and surety to enable the principal to set-up one North
Carolina labeled modular building.
2. This bond is in full force and effect as to the above State Building Code obligations of the principal
for the set-up of one North Carolina labeled modular building at the following address:
Address: Irks Corner- Holly Springs N 27540
This bond will remain in full force and effect for one year following the issuance of the certificate of
compliance for the modular building.
4. The bond must remain on file with the Harnett County. S inspection department.
5. The owner of the modular building described in paragraph 2 who sustains any loss or damage by
reason of any act or omission covered by this bond may, in addition to any other remedy that he may
have, bring an action in his own name on this bond for the recovery of damages sustained by him.
6. It is further understood and agreed that this bond shall be open to successive claims up to the face
value of the bond. The surety shall not be liable for successive claims in excess of the bond amount,
regardless of the number of claims made against the bond.
In Witness Whereof, the above bounded parties have executed this instrument under their several
seals, this day, 8/15/2006, the name and corporate seal of each corporate party being hereto affixed and
these presents duly signed by its undersigned representative, pursuant to authority of its governing body.
Quail Run Homes, Inc.
Merchants Bonding Company dba Carolina sWrn Builders
Surety Principal
By:
Attomey-In-Fact Timothy S. Halt Signature of Pri cipal Title
P. G. Box 16209, Greenville, SC 29606
August, 2006 M NCM00 1
f Merchants Bonding Company
E (Mutual)
POWER OF ATTORNEY
Know All Persons By These Presents, that the MERCHANTS BONDING COMPANY (MUTUAL), a corporation duty organized under
the laws of the Stale of Iowa, and having its principal office in the City of Des Moines, County of Polk, State of Iowa, hath made,
constituted and appointed, and does by these presents make, constitute and appoint
Timothy S. Holt
of Greenville and Slate of South Carolina its two and lawful Attorney-in-Fact, with full power
and authority hereby conferred in Its name, place and stead, to sign, execute, acknowledge and deliver in its behalf as surely any
and all bonds, undertakings, recognizances or other written obligations in the nature thereof, subject to the limitation that any such
instrument shall not exceed the amount of;
ONE MILLION FIVE HUNDRED THOUSAND ($1,500,000.00) DOLLARS
and to bind the MERCHANTS BONDING COMPANY (MUTUAL) thereby as fully and to the same extent as if such bond or
undertaking was signed by the duly authorized officers of the MERCHANTS BONDING COMPANY (MUTUAL), and all the acts of
said Attorney-in-Fact, pursuant to the authority herein given, are hereby ratified and confirmed.
This Power-of-AOomey is made and executed pursuant to and by authority of the following Amended Substituted and Restated By-
Laws adopted by the Board of Directors of the MERCHANTS BONDING COMPANY (MUTUAL) on November 16, 2002.
ARTICLE 11, SECTION B - The Chairman of the Board or President or any Vice President or Secretary shall have power and
authority to appoint Attomeys-in-Fact, and to authorize them to execute on behalf of the Company, and attach the Seal of the
j Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature
thereof.
ARTICLE 11, SECTION 9 - The signature of any authorized officer and the Seal of the Company may be affixed by facsimile
to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking,
recognizance, or other suretyship obligations of the Company, and such signature and seal when so used shall have the
same force and effect as though manually fixed.
In Witness Whereof, MERCHANTS BONDING COMPANY (MUTUAL) has caused these presents to be signed by Its President and
j its corporate seal to be hereto affixed, this 16th day of January, 2006.
w NG.... MERCHANTS BONDING COMPANY (MUTUAL)
Aq:9y,
•0~ OA10
b
1933 r c' By
/~e'7
STATE OF IOWA • • President
COUNTY OF POLK ss.
j On this 16th day of January, 2006, before me appeared Larry Taylor, to me personally known, who being by me duly swom did sny that
i he is President of the MERCHANTS BONDING COMPANY (MUTUAL), the corporation described In the foregoing instrument, and that the
Seal affixed to the said instrument is the Corporate Seal of the said Corporation and that the said instrument was signed and sealed in behalf
of said Corporation by authority of its Board of Directors.
In Testimony Whereof, I have hereunto set my hand and affixed my Official Seal at the City of Des Moines, Iowa, the day and year first
above written.
{{f'
CINDY SM'I"
!+F Commission Number 173604
My Commission Explrea UUU
March 16, 2009 Notary Public, Polk County, Iowa
STATE OF IOWA
COUNTY OF POLK as.
1, William Warner, Jr., Secretary of the MERCHANTS BONDING COMPANY (MUTUAL), do hereby certify that the above and foregoing
j is a true and correct copy of the POWER-OF-ATTORNEY executed by said MERCHANTS BONDING COMPANY (MUTUAL), which is
I! still in full force and effect and has not been amended or revoked.
In Witness Whereof, I have hereunto set my hand and affixed the seal of the Company on this day of /yN yG4T ~6
,oa0,AG Q4jpq
•0
• : OP
a'• 1933 Secretary
POA 0001 (1106) • 'b''~y':