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BUILDING Application # / 9 2 9 • Each section below to be filled out Harnett County Central Permitting by whomever performing work. Must be owner or licensed PO Box 65 Lillington, NC 27546 contractor. Address, company 910 -893 -7525 Fax 910- 893 -2793 www.harnett.org /permits name & phone must match P Application for Residential Building and Trades Permit Owner's Name: IC.Ae%C\L Z:n4 gL ✓. Date: 74(0//0 Site Address: SS 0(ai_ . Cott L / .A._ Phone: 809-22 -7v97 Directions to job site from Lillington: S E E- A-0 --ccr. k- Subdivision: 1 e. t 5 rn cf .-‘, ki \ \ Lot: Description of Proposed Work: bL':l'- 3 -a So." Sr, .. roarer # of Bedrooms: a Heated SF: 0 Unheated SF: © Finished Bonus Room? `7 Crawl Space: t Slab: \IPS General Contractor Information cncis .O.0, o-, 1i. , v‘■ � c m,,J s 4[9 i i ' ( , e —G Building•Contractor Company Name rn -- � Telephone (� 3 00 tionn x.: r„(1./1 \ Y-1 IV :Cv\4/ As- roieif'l,.pfrn re cvrr():., � +r. ,',ve ll -COI -, Address Email Addre L 4/6.9e_ Si ure wner /Contractor / Officer(s) of Corporation License # Electrical Contractor Information AA. R n Description of Work 4 om- \S 2. Su-k... Service Size: Amps T -Pole: _ Yes / No Pr\p;r■.. C r-.lrc4 t L 9/9 C. s - Electrical Contractor's Company Name Telephone 9 34 Sinn � r:,1C cn c-.r r.c, 7 ABC Ad ress / Email Address r /�' 2/743-0o Signature of Owner /Contractor /Officer(s) of Corporation License # Mechanical /HVAC Contractor Information Description of Work Mechanical Contractor's Company Name -lephone Address Email Address Signatur • Owner /Contractor / Officer(s) of Corporation License # Plumbing Contractor Information Description of Work # Baths Plumbing Contractor's Company Name Telephone . • Address Email Address Signature of Owner /Contractor /Officer(s) of Corporation License t Insulation Contractor Information Insulation Contractor's Company Name & Address Telephone 'NOTE: General Contractor must fill out and sign the second page of this application. • I I - 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 Harnett County Zoning Ordinance. I state the information on the above contractors is correct as known to me and if a 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 5150.00. After 2 years re -issue fee is as per current fee schedule. • 772 � Sgua ntra r /Officer(s) of Corporation Da e j C Affidavit for Worker's Compensation N.C.G.S. 87 -14 The undersigned applicant being the: X 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: X 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. A 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 Name: l `7 o at SCis LAN" / 9 � `� . `� Sign w /Title: �_ • J_ � � • T Date: i I i i I I ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LS DATE IMM DD YYVY) CHAMP - 12/01/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Roeding Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2734 Chancellor Dr ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Crestview Hills KY 41017 Phone : 859-341-0202 Fax:859- 341 -3709 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA OHIO CASUALTY 24074 INSURERS: INDIANA INSURANCE COMPANY 22659 Champion Window Company of INSURER Sent Insurance Raleigh Durham, LLC rY 300 Dominion Drive #201 INSURER I/ Morrisville NC 27560 INSURER E'. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MOH AFL POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSRC TYPE OF INSURANCE DATE (MM/DDIYY) DATE (MM /DD/YY) LIMBS GENERAL LABILITY EACH OCCURRENCE $1,000,000 _ A X COMMERCIAL GENERAL LIABILITY BKA53758 12/01/09 12/01/10 PRE $ 100,000 _ CLAIMS MADE X . OCCUR MEDEXP one person) $10,000 PERSONAL B ADV INJURY $1,000,000 _ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000, 000 n POLICY 28, In I LOC . AUTOMOBILE LIABILITY COMBINED accident) LIMIT $1,000,000 ANY AUTO Ea accude ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BAA53758486 12/01/09 12/01/10 BODILY INJURY A X NON -OWNED AUTOS BAA53758486 12/01/09 12/01/10 (Per accident) $ ' PROPERTY DAMAGE $ • (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ !ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $10,000,000 B X IOCCUR CLAIMS MADE CU8319330 12/01/09 12/01/10 AGGREGATE $ 10,000,000 DEDUCTIBLE X RETENTION $ 0 $ WORKERS COMPENSATION AND X WLSIAIU- UIH- EMPLOYERS' LIABILITY TORY LIMITS Eft C ANY PROPRIETORIPARTNEREXECUTNE 90162320100061 12/01/09 12/01/10 EL. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000 I yes, deibe under SPECIAL P below E.L. DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS • CERTIFICATE HOLDER CANCELLATION BLANKXX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Information Purposes Only IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Marc Tessel ACORD 25(2001/08) © ACORD CORPORATION 1988 I I . i I I I • III Plan Box Number Rap . Job Name p . �-- Date: - ( 3 Required Inspections for SFA /SFD Appl. # ( So c z 4 -j 5 6 y Valuation?` 2? Y Sq. Feet 2 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. N4 =b L . 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 Four Trade Final 60 Four Trade Final > 2500 60 Fhree Trade Final 60 Three Trade Final > 2500 60 ✓ Two Trade Final 60 Two Trade Final > 2500 ° 60 One Trade Final 60 One Trade Final > 2500 999 linvir. Operations Permit