BUILDING 'Each section below to be filled out Application # /(/ - L iz/
by whomever performing work. Harriett County Central Permitting
Must be owner or licensed PO Box 65 Lillinglon, NC 27546
contractor. Address, company 910-893-7525 Fax 910 - 893 -2793 WAY . harnett.orglpermits
name & phone must match
Application for Residential Building and Trades Permit
Owner's Name: Wellco Contractors, Inc. Date:
Site Address: 149 Caldwell St., Spring Lake, NC 28390 Phone:910- 436 -3131
Directions to job site from Lillington: Take 2105 to Ray Rd. -Make right onto Overhills Rd.-
Make right onto Lenoir Dr. -Make left onto Caldwell St. -Lot is on left side.
Subdivision: Overhills Creek Lot: 574
Description of Proposed Work: Construction of single family home# of Bedrooms: 3
Heated SF: 2132 Unheated SF: 473 _ Finished Bonus Room? Yes Crawl Space: X Slab:
General Contractor Information
Wellco Contractors, Inc. 910 - 436 -3131
Building Contractor's Company Name Telephone
513 Holland Plaz , Spring Lake, NC 23890 anthonyblanks @ymail.com
Address • Email Address
74
g An/ ntrac r/0 Icer s of Corporation
License #
Electrical Contractor Information
Description of Work Electrical complete Service Size: 225 Amps T -Pole: Yes No
D2 .Electric, Inc. 910-498-0463 --
Electrical Contractor's Company Name Telephone
100 Hidden Creek Lane, Lillington,. NC 27546 24311 -L
Address Email Address
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gnature of Owner/Contractor /Officer(s) of Corporation License #
Mechanical /HVAC Contractor Information
Description of Work Heating & Coaling
Simmons Heating - Cooling- Electrical 910 - 739 -3333
Mechanical Contractor's Company Name Telephone
1110 East 2nd St., Lumberton, NC 28358 02875
Address Email Address
S': nat ' e of Owner /Co actor/officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work Plumbing complete # Baths 2 1/2
Vance Johnson Plumbing Co., Inc. 910 - 424 -6712
Plumbing Contractor's Company Name Telephone
3242 Mid Pine Dr., Fay., NC 28306 7756 -P1
Addr1gsi // Email Address
x 1W LG 'n4
Signature of Owner /Contractor / Officer(s) of Corporation . License #
Insulation Contractor Information
Tri City Insulation, Inc., 334 East Mountain Di.., 910 - 486 -8855
Insulation Contractor's Company Name 8 Address Fay., NC 28306- Telephone
. *NOTE: General Contractor must f111 out and sign the second page of this application.
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 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 any 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 cur ent f- - : - edule.
Ir��� i�_ Oct. 19, 2010
Signature of 0 . • er /Con ractor 1 Icer(s) of Corporation Date
Anthony Bl.nks — General Manager
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), liirrt(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.
X 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: Wellco Contractors, Inc.
Sign w/1'itle: ity4>�
a Date: 10 -19 -10
'Anthon Elan :_ — General Manager