BUILDING • Each section below to be filled out Application # /t/ S2 l/ Z S 37
by whomever performing work. Harnett County Central Permitting
Must be owner or licensed PO Box 85 Ullington, NC 27546
contractor. Address, company 910 -893 -7525 Fax 910-893-2793 www.hamett.orglpermIts
name & phone must match
AogllcatIon for Residential Building and Trades Permit
Owner's Name: Blackwell Homes Inc Date:
Site Address: Phone: 919-320 -8256
Directions to Job site from Lillington: 27 N to Nursery Road. Left on Nursery. Anderson Creek Entrance is 3 miles
on left.
Subdivision: Anderson Creek Lot:
Description of Proposed Work: New Construction # of Bedrooms: 3
Heated SF: Unheated SF: Finished Bonus Room? ✓ Crawl Space: 1 Slab: _
General Contractor Information
Blackwell Homes Inc 919 - 359 - 0079
Building Contractor's Company Name Telephone
PO Box 189 Clayton NC 27528
Address Email Address
52830
Signature of Owner /Contractor /Officer(s) of Corporation License #
Electrical Contractor Information
Description of Work New Construction Service Size: Amps T -Pole: I Yes No
Pioneer Electric 919 - 499 - 7767
Electrical Contractor's Company Name Telephone
80 Neill Thomas Rd. Lillington NC 27546
Address Email Address
21643 - 0
Signature of OwnerlContractor /Officer(s) of Corporation License #
MechanicallHVAC Contractor Information
Description of Work New Construction
Carolina Comfort 919 - 934 -1060
Mechanical Contractor's Company Name Telephone
Hwy 70 Business West Clayton, NC 27527
Address Email Address
29077
Signature of Owner /Contractor / Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Construction # Baths 3-5
Jamie Johnson Plumbing 910 - 279 - 4742
Plumbing Contractor's Company Name Telephone
1490 Clark Rd. Lillington NC 27546
Address Email Address
21649
Signature of Owner/Contractor/Officer(s) of Corporation License #
Insulation Contractor Information
Tri insulation 910 - 486 - 8855
Insulation Contractor's Company Name & Address Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
• Each section below to be filled out by Application N
whomever performing work. Must be owner Harnett County Central Permitting
or licensed contractor. Address, company p0 Box 65 Lillington, NC 27546
name & phone must match information on Telephone Number 910- 893 -7525 wvmn.harnett.org
license, Application for Building and Trade Permit
Owner's Name: Date:
Address: Phone:
Directions to job site from Lillington:
Subdivision: Lot.
Construction Type: (Please Check) Building Use: (Please Check)
_ New Moved House Residential _ Commercial
Renovation _ Addition _ Other _ Modular _ Multi- Family
Total Project Cost: Description of Proposed Work:
General Contractor Information
Heated SF _Crawl Space ( ) Building Construction Cost $
Unheated SF Slab () Acres Disturbed Stories 1
5 7 4 .r . N�o.aa 9/9- Ca. - va6 CKlD1�'� c e
Building Contractor's Company Name Telephone Ot `. C
Z SA1 on --1 0 ,u 094 C.e•.l. $...f{ //r & r As- .71v-I/ 5 --Z,s 3 e. °I V"
A� License # l
gnature of Owner Contractor/Ofticer(s) of Corporation — Moat sign beck of form 8 workers comp
// Electrical Permit Information
Description of Work �M/eittel / _Vo rK Electrical Cost $
TS Pole:. Yes () No ( ) Underground ( ) Overhead ( )
Permanent Service: Underground ( ) ? Overhead ( ) Service Si e: Amps
.orme t «ke r %°.i;rhana!°r lint. 9n 9p
Electrical Contractor's Company Name Telephone
?04 r.• - aa,I /,.- " fl al zsyrl ,-,2/6 %3 -/>
Ad� License #
`
Signature of Officer(s) of Corporation
Mechanical Permit Information
Description of Work __. --_ ... __
robot of Unite may, Type System Mocha ical�Gist
•rncal Ca C �t - C n any "ill el :. •ng • P.11
Add!• ,- (1, • y '1 L.IC9119e tY •
S •. ' • re of Otficerta) of Corporation
Plumbing Permit Information
Description of Work >' L" hl: a
Number of Baths `L Plumbing Cost $
Jkivtit J ti s... P1‘.,-.1.1)/7
Plumbing Contr Company Name Telephone /j 4
e C1rtrk l° , L:)1,n _ .,J.L. ;2 -'7SY gat 9
Address License #
S, iatture of &L(s)otCorporation
Insulation Permit Information Residential ( ) Other ( ) Not Required ( )
jt , .4n n 1/a c/2 6 --- .335 "
Insulation Cont � ract r s Company Name & Andress Telephone
Page 1 of 3 1/07
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 gny 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 per current fee schedule.
2Ati /612014
Signature of Owner /Contractor /Officer(s) of Corporation Da
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.
✓ 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: Blackwell Homes Inc.
C r �(/
Sign w/Tltle: - t D ate: r
LAC ,KW E L L
- - - - - -- - H Q M E S
Fax
7b: VC Brown From: Dustin Blackwell
Fax1 910 -893 -2793 Fax: 910 - 8084363
Phone: Emall: .
Re: 10- 50025384 Date:
❑ Urgent x For Review ❑ Please Comment x Please Reply ❑ Please Recycle
VC,
The scope of this project changed and now the value exceeds $500K I need to change the GC from
DBI (limited license) to Blackwell Homes, Inc (unlimited license). Following is the paperwork to support
this request. Let me know if you need anything else.
Dustin -
I . d 1QQI•ON aai110 uoi2u11111 WrdA7:E 007 *C7.•lo0
Application# 'Soo 25384
by a � 0tt Harnett County Central Permitting
Must be owner or Masted PO Box 851.®rgton, I C 27548
ardmctor. Address, company 910-893-7525 Fax 910 493 -2793 www.hamettorglpermgs
name & phone must match
Aonlicatlon for Residential B'ukdlna and Trades Permk
•
Owner's Name: Date:
Site Address: Phone:
Directions to job site from Lillington:
Subdivision: Lot:
Description of Proposed Work: # of Bedrooms:
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: _ Slab: _
General Contractor Information
2 4 . w et RI:wax% r-'-- gi9 'o6 --f6
Building Contractor's Company Name Telephone •
9 la 4 Nth', AC 7 5 t it nib Ftril e rtclf
Addres Email Address
Sign ture of Owner/Contractor/0L(s) of Corporation License #
Electrical Contractor Information
Description of Work Service Size: Amps T -Pole: Yes No
Electrical Contractor's Company Name Telephone
Address Email Address
Signature of Owner/Contractor /Officer(a) of Corporation License #
MechanlcaUHVAC Contractor Information
Description of Work
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature of OwnerlContractorl0fflcer(s) of Corporation License #
Plumbing Contractor Information
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Emad Address
Signature of OwnerlCont actorlOffcer(s) of Corporation License #
Insulation Contractor Information
Insulation Contractor's Company Name & Address Telephone
`NOTE: General Contractor must fill out and sign the second page of this application.
Residential Buikling Application 1 of 2 03/10
7 H igal'OM 83l110 UO12UI1 1 WdBg :£ OIOZ '9Z'130
Homeowners Applying to Build Their Own Home
mum maw urn roeoaAnw questions then see s Panrdh redmdan to determine r you quay for panne under Oren Exemption.
Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Nero avairabN 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 an 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?
__ yea _ no
I hereby certify that I have the authority to males necessary application, that urn application is correct
and that the constucllar will =form to the regulations In the Building, Elecb+cel, Plumbing and
Medhardad codas, and the Harnett County Zoning Ordinance. 1 state t» Irdbrmation on the above
contractors is coned as known to me and if figx charges occur including listed contractors, site plan,
number of bedroans, buliding and trade plans, Environmental Health permit changes or proposed use
changes, I amity Nis my responsibility to nosy Its Harnett County Central Permitting Department of
any and et changes,
EXPIRED PERMIT FEES - 8 Months to 2 years permit reissue fes is $15000. Alter 2 years rs -Issue fee
Is edheduls.
,� 1$i� /Con Y '
(s) of Corporation Oats
Affidavit for Worker's Compensation N.C.3.8.87 -14
7hs undersigned applicant being the:
Y e General Contractor Owner Officer/Agent of the Contractor or Owner
Do hereby amen under penalties of perjury that is person(s), firm(s) or corporation(s) petomnhg the work
set forth in the permit
Has three (3) or more employee) and has obtained workers' compensation insurance to cover then.
Has one (1) or more eibconbadors(s) and has obtained workers' compesadon inmate e to cover
tam.
Hee one (1) or more subwntractords) who has their own policy or workers' compensation haven=
covering themselves.
Has no more than two (2) employees and no subcontractor.
White working on the project for which this permit Is sought it is understood that the Central Pemitting
Departmek issuing the permit may require certificates of coverage of worker's compensation insurance prior
to issuance of the permit and at any this during the permitted work from any person, firm or
carrying out the work. L corporation
Company or Nall: (aGL AAA& fl&fte( i Z ti
Sign wattle: el A � � e £J /0/2-4
8/21/08
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