BUILDING • Each section below to be filled out by I / /�j Oa z 1 / / ,[/ ✓/
whomever performing work. Must be owner Application # (/ ✓ ! (p /// /
or licensed contractor. Address, company Harnett County Central Permitting
name & phone must match Information on
license. PO Box 65 Lillington, NC 27546
910 -893 -7525 Fax 910 -893 -2793 www.hamett.org /permits
r
,..----.. Application � for Residential Building and Trades Permit
Owners Name: VA "3 - • '.r0\1 (Ai , hl- Date: (al - 11 ) 0
Site Address: 45 ian(7aeu snvr \ G ,. -e Y; ue_ Phone: G1G Ring - 1`1 - 1 as
Directions to job site from Lillington: IO ( &'3 * \\ �� f\ '9- "-JL >I y e_ t 0
VA C � I ),(4 of 1 l . l `` rv2 - W O (OY1�t, ant- \ a 1 /�� �a -- "7 ;in ( \_'
of 1 t 1AC V1hf , V C \' \ \00)9 \-- 4'��CANsOn 'r `^V 4
Subdivision: t• a .r\ eek 0..3( ( \ v. Lot: 3\-i
Description of Proposed Work: S\1 �
\e c"\: \y \ � orine #Bedrooms: - 3
Heated SFa5CIh Unheated SF ( Finished Rec Room? le s Crawl Space Slab ( )
General Contractor Informs on
p 1
Building Contractor's Cdnpany Name Telephone
-P.95 \ e\e( �c■ve �t\c1�e� t 4.3C - o rs b \ ( e0' g
Address Q (/ License#
�C Must sign & fill out second page
Signature of Owner /Contractor / Officer(s) of Corporation
Electrical Permit Information
Description of Workh \ Service Size: S.00 Amps TPoI:C no
M1JlVei e E\ec\Yi[c. -\ (5 -Tv. Ct 1 B`18- 4to -
Electrical Contractor's Company Name Telephone
s °01 C( eea\rv\ooz el- �w \ y2i4\ . �L 2-140 \5 .
Address 1 License #
Signature of Officer(s) of Corporation
l Q\ Mechanical /HVAC Permit information
�`
Description of Work `1 \\o \^nt \\ *NC. a- „,..)e rtT�r\
\(\nU\m \\ms
e\ ok \ck - j)3 s - \-P -a
Mechanical Contractor's Com any Name Telephone
S h \\ \ec.se. \\A. 0. \eCr�h. 13 (--
Address License #
Signature of Officer(s) of Corporation
\ Plumbing Permit Information
Description of Work L e.� A 't e RLzv\ c # Baths ot , S
c Rco\e R 1 \J\'V\hom,t 914 - (o4 , i - [03333id
Plumbing Contractor's Company Name Telephone
310A tot (onoca - - Di , G f u'r , 13c_ ,c7.5
Address License #
Signature of Officer(s) of Corporation
Insulation Permit Information
• R \ \WO r. SU\- -Kr \Ow \ 0•3, it; \ \e , w ( — `WI 55`( - 500
Insulation Contractor's Company Name Address Telephone
8/21/08
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you qualify for permit under Owners Exemption.
Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo available upon request)
1. Do you own the land on which this building will be constructed? _ yes _ no
2. Have you hired or intend to hire an individual to superintend and manage construction of the
project? _ yes _ no
3. Do you intend to directly control & supervise construction activities? _ yes _ no
4. Do you intend to schedule, contract, or directly pay for all phases of construction work to be
done? _ yes _ no
5. Do you intend to personally occupy the building for at least 12 consecutive months following
completion of construction and do you understand that if you do not do so, it creates the
presumption under law that you fraudulently secured the 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 Hamett County Zoning Ordinance. I state the information an the above
contractors is correct as known to me and if a y changes occur including listed contractors, site plan,
number of bedrooms, 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.
EXPIRED PERMIT FEES - 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is as • r t f sc dulp ,/
6/4/
ignature of Owner ontractor /Officer(s) of Corporation Date / /
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
General Contractor 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 three (3) or more employees and has obtained workers' compensation insurance to cover them.
_ Has one (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover
them.
)c Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance
covering themselves.
Has no 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.
Company or N- me: Fk0 01/4Vii
Sign w/Titl= (( 4 - tv\oer e ✓ Date: (p) 10 .) r
8/21/08
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Jun. S. 7 i:1 G 1 1 : C3+1h9 CERTIFICATE OF INSURANCE No, 1464 2 . 1
Farm Bureau Insurance of N.C., Inc.
North Carolina Farm Bureau Mutual Insurance Company
This is to Certify, that policies in the name of
IN D Vahue Building Corp L L C
and 285 Wheeler Dr
ADDRESS Angier NC 27501 THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR
NEGATIVELY AMENDS EXTENDS OR AERS T HE COVEA
I — J AFFORDED BY ANY POLICY DESC HE REIN RGE
.
are In force at he tale hereon, as follows: _
POLICY EFFECTVE POLICY TION
TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDRY) DATE (�pRY) ALL LIMOS IN THOUSANDS _
COMMERGUq{• ii GL AGGREGATE $ 1000
GL 0474941 6/20/2009 6/20/2010 PRODUCT - PI!P A,G;, , $ 1000
GENERAL PERS NAL& ADVERTISING IN URY $ 1000
LIABILITY EACH OCCURR NCE $ 1000
FIRE DAMAGE iANY ONE FIRE) 8 100
MEDICAL EXPENSE (ANY ONE $ 5
AUTOMOBILE LIABILITY ___, CSL $
SCHEDULED AUTOS BODILY
HIRED AUTOS INJURY
(PER PERSON) $
NON -OWNED AUTOS BODILY
GARAGE LIAUILITY INJURY
(PER ACCIDENT) $
PROPERTYOAM $
AGE • -- --- 1 1I
EXCESS UABILITy I EACH AGGREGATE
UMBRELLA OCCURRENCE
OTHER THAN UMBRELLA $ $
FORM
WORKERS WC 023465 6/20/2009 6/20/2010
STATUTORY T 4 € ' ,- J
COMPENSATION $ 100 (EACHACCIOENT)
AND $ 100 (DISEASE -EACH EMPLOYEE;
EMPLOYERS LIABILITY NORTH CAROLINA W.C. COVERAGE ONLY
-
$ 500 (DISEASE•POL ICY LIMIT)
OTHER — _J______ _ _ I ___ {
( ADDITIONAL INSURED (IF ANY): ` - J
- -
DESCRIPTION OF OPERATIQNa fSPECb1L ITEMS:
In the event of any material change in, or Cancellation of said polices. the undersigned company will endeavor to give whiten notice to the party to whom
INS WV/Cale is issued, bit failure to give such notice shall impose no obligation nor liability upon the company.
Dated:6 /8/2010
JOB LOCATION: Name of
Company:North C, op : Farni Bureau M. ua Insurance Co.
iAP / , `- ..iA'...
CERTIFICATE ISSUED TO; AUTHORIZ: D REP ESENTAT
NAME H arnett County
and
ADDRESS
L_ _J
505105 -000JA797 -21
06/21/2010 13:00 9196394464 MARTY VAHUE PAGE 01
L ?. i p.
[lily ; ! : V[ n: CERTIFICATE OF INSURANCE +o. p.r i
Farm Bureau insurance of N.C., Inc.
North Carolina Farm Bureau Mutual Insurance Company
' PPP !f This is to Certify, that policies In the name of
tame • Vahua Building Corp L 1 C
l AD
INSURED 28S Wheeler Dr C6R p �� p �
DR@5a Angier NC 27501 TM GA1 r
TI i D in o T
1 L J
•
nn (eV/URA/180 POLICY Myrna P ee � n+i F likfilelloqr ALL L orre IN 1HOUSAM • $
1 re in cefuttolowt se—.--.
$1000 1
COMMERCIAL GL 0470841 820/20 8/20/2011
4 y�uvr analNawxRV $ 1000
aPIERAL $ 1000
�
I L I A B I L I T Y $ A n ti nOWININC DAMAGE (ANYONE FIR61 $ 100
MapICAI fLXPtF1fa6 (ANA ONE $ _ 1
1 [AUTOMOBILE MAR LOY Y _ Cei , $ —
SCHEMA PD AUTOS SLY
PORED AUTOS (PER PERSON) $
NON -OWNED AUTOS v $
�l ""--- GARAGE LIABILITY (PER ACCIDENT) . , A
J'— PROPSRrY DAMAGE $ .
EXCEsa LIABILITY EACH AGGREGATE
OCCURRENCE
UMBRELLA $ $
oTHER THAN UMBRELLA
FORM
I • r S TATUTORY 6' T. • s'
'ID WORKERS WC 0234688 i6/20/2010 1 x/2012011 $100 (EACH ACCIDENT COMPENSATION $ 100 (D aE abfaCN EI LoYE£)
AND NOUTN CAR W.
OLINA C . COVERAGE ONLY
EMPLOYERS LIAR {CITY $ 500 lorAEAeE.POUCV uteri
OTHER L __- --
AODITIONAL INSURED or Awn.
I, DEBCRIr110N Or OPERATIONSILQCATIOMSN ENICLCSIRESTRICTIDMSBPECIAL. tuna:
i
In Ins gaol of any materiel things In, or cancellation 0 said policies, the understood company will endeavor to 9S written notice to the pan enure
ure
Sued. certificate IS ued. but fen to pin text) notice shall impose no rogation Ivor Ilexes/ upon the mnpfl.
I
� Dated:b/16/2010
.108 LOCATION: Name e1
cotnpany:North C.' F arm B ureau Mut ' In ante Co.
t . A.. r4_ #..a
pUrtCR4r RE" NTArivE/
�� CERTIFICATE ISSUED TO: I
�!i. r —I
I K � E Harnett County
ADDRE9a
b6105- 0003.d79
I
1
V'
Iii
J c2
v ES-Car
Plan Box Number R3 Job Name (l s r
Date: 6 - ,2,) - l O
Required Inspections for SEA, SFD
Appl. # ] -s C cs,24 Ey q
Valuation 2 -( C
Sq. Feet R6 q 9
Sequence
10 R* Bldg. Footing
10 -30 R* Elec. Temp Service Pole
20 / R* Building Foundation
20 Address Confirmation
30 -999 Open Floor
30 -999 R* Bldg. Slab Insp.
30 -999 R* Elec. Under Slab
30 -999 R *Plumb. Under Slab
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 > 2500
50 R* Insulation
60 Pour Trade Final
60 f Four Trade Final > 2500
60 Three Trade Final
60 Chree Trade Final > 2500
60 ' Iwo Trade Final
60 Two Trade Final > 2500
60 One Trade Final
60 One Trade Final > 2500
999 Iinvir. Operations Permit