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09/09111 Applicationp # Harnett County Central Permitting 1 x-x,U Lb'� 'a Each swum Mbw b ba Wed out PC Sex 65 tAnQlon NC 27546 by whomever perkarung work 910 893 7525 Fax 910 893 2793 www homed erg/permits Must be owner or licensed 0°ntrecta Address 00Ameny Apobc.tton for Rutdentml Budding and Trades Permit name 6 phone must meth D /� Owners Name -Thicecg ranrii Gat 100005 $/� JJ Date Site o T N . t1 LI Ilii 1 Phone 4/0_43(. !7(p Directions to job site from Lillington grad Onp�'d�oy� } .�, .b� 5 jz Vit.. Cotihn, e on US 421 ;r 4 Subdivision -lllOmss 1.430-4-ef Lot 5 Description of Proposed Work PO-...J SF #of Bedrooms 3 Heated SF3,012 Unheated SF ',VI_"7 Finished Bonus Room'?_,No Crawl Space L Slab Mn stgani Contrseter tn,enntm sas '+row names ,.g ,jr., Inc. Telephone9 24-44GC-/9l9-cowls,' Budding Contractors Company Name ¢ .. . • a Sigq nal/0114)So,, nQ6,1.,ah,n,a.ccw, Ss3lo2 // .+ 7 hslnatl Andrus License N I Daaptan or wont /fin.., ol,,it-i Ems 00Amps T-Po. nu No �r Scat-sc 419-303—(e2,(o *Company Nem. Telephone 112,0 Bx*aP t Pc- 2is39 IwnaM.rbcan Ada sl egi cigatillaletflartitanahasamima _ Ems Address DI.arpuon° Work &k, Fl t ackrie . Pur"art .404 Ater t1et SMP Air Aleche eel r5 MA:w- C;,edi{iranvlg Telephone 44 78'880Q 9120 Old de i PaC;A., At- E76i0 kimV,UL,�arw scoen Address Cl EmaiAdda� Longed Dgcnpbonofwak Mt,,r Plumbtt�pt seams & c Moe, Wall TionbitrQ J�� AS(4-3775-83415' Plumbing Ca na for$ConpangBwne Telephone us Winton SF.I Gres lzen„ ac 2x/ns" l3natAaWdmfili ►amici lama batialscon. n.ow.CGo t t o C+ = , MC 919-772-9000 icy am.B Address 27(,03 Telephone 'NOTE General Contractor must MI out and men the s..ata page of this apPlroabon MOW 1 Application N Harnett County Central Permitting Sas 06 NC 275443 by Each whomeverpelamtng Mbw b Mork out 610 Bea 7525Po a MD Bea 2ie3 hermit mes orpiment'sMusst or MOMS comprer mti6 onst APY �romRrdtaB _ awmen mumatch Owners Name 1.. ..! • as •_ - _ ctIO • See Address 11 Dale '-.• '1. 'I.i .u., Phone 9/U- 4(, !7( Directions to job site from Edlington .. • . a� . .}i • its... ue}. ' v . a. St Jr . Subdivision �n ah m . Desaipoon of Proposed Work gyp. SF{7 Lot $ Healed SF 01`2- Unheated SF t #of Bedrooms _� Finished Bonus Room'Sii__Crawl Space AL Slab 91021afagtflaeuntsuranua ro 919- 72q L (c/919- p Contractors Company Name t TalTelephone (al P-r5-79 aom (9,gW .. \tnP {k�+ISnn 1Sn74 nn��o ks -- hornes.awlAddrsas 4,82 Email Address License N Desmpoon of Work S-I ale -� Baterrini/t "tO°Amps T-Pole Yes No Rs. :c 2419-30-- _ 11?� B-cno 9r c- Telephone AGMs2'7539 Vd.r•lircress K, coM ZN 9R(a Email Address License I Descnpoon of Work . .l.___.a. . . .. . .es . _ nt .. ,.• r • 919' IF : '� Methanipt Contractors • •• .� .. r • • ny Name 120 01. •.. . 2d • Address . . r. ‘s •��,'•�r.��••n • ..•_tea. coM Rto9 aaae �'aW r License ^.1•. 1• 1 ..r OeearMmnof Work Nq 41umbtcW � . mites 3.5 Cara i UPIOrnbinci. 33(42 -3731R3G45 %robsq Contractors Company.blame Telephone ASI Wins}m ., G eerSEorQ JC 271-105" - allAddr:.e I. v . , • tci • s5 License* Insulation Contractor Information ne _kCnQ ;sC1142 !'Inm- C+, iho vn) A1C 9/9-772-9600 insulation Name a Address Telephone 27603 NOTE General Contractor must tri out and eon the second papa of that application og/og,t 3 Application# ion NC 27548 Each sedanHarnett County Central Permitting whomeverPby belowm be out 910 8937525 FOaB 910 7t�i703 www homed wypemun Must be owner la icense� d am eotor Address comma A aintatatuizma names phone must match onlrutton for Roldenbal B ddln Owners Name legis, • e • G_(10 • Site Address , a . I I. Date 1. /(a Directions to lob site from Lularri lington • n e Phone 9/U_4i S17 . .�i w. . • ee•��}. ' v ' rp ' 'rzd•i, Subdivisionn...,_ Ay,w Description of Proposed Work _NQyJ SPD Lot s Heated SF.t91:_2- Crawl Unheated SF 1 ° 7 Finished Bonus Roomy o Spacit of e General ConMtl r . gg Pa Slab rnagg r�8—g ccooran2 Rd, �t lso �O �" 919- b- - CpIP-r qouontractor pang Name Telephone ail ' � .ra„nAddress Email Address License# Dest»pton of Work .9 r.• . ¢letrl�p SpviceSoa 00Ampe T-Pole )(tee No +`Zal&ta maters mnyNacme-tc 9/9-303— 92(4 ElectroahContrador u Company Name telephon e II I,� 1.1c- Address 27539 r`r'lafyn�grti-F�o.r'l' coin Address l• r�- Vt�li Zy eN(O Email Address License# MacSemcaleNAC Contractor Infomtebog Description of work &kid.' EIeck,1 . rttnarP _t/ H Ade, _Ft-Any Aie rr o ors 0-enaing era Air C'„ d;� nioninp 919' 878-8800 Mechanical Contractor a Comeny Name J Telephone 511 2-0 Old ode Rd iy NIL27(ot0 r herlW@a an-Akers M rs co Address Email McCue ggo9 License# plumbing Contractor Information Description of work Me...) (P1urnbt e. Olathe 3.5 lode, Wall 71)Ii-tn1:dt^^yy .33(.4 -375-13CI5 Plumbing Contractor s CompanyName Telephone 516 Address Winsiwn SF. Green�or4 t1C £,qo .-.t• _ .. # u •i , ! LGf. .'L Q G / 7- ail Address i License 8� /I/ /'� '7/ Insulation Contractor�,,�i�nfao�rmation IACJ(O i nick Inc. 1112 I4nens C+t ?<blet�r AIC 9/ 9-772-95°0 Insulation Contractor Corepany Name I Address 27(403 Telephone 'NOTE General Contractor must fill out and sign the second page of this application 09/09/11 Application# Harnett County Central Permitting Each seoeon bsbw to be Med out PO Box S5 LIINnpton NC 27518 910 893 7525 Fax 010 993 2703 www hernia org/per by whomever performing work mib Must be owner or licensed contractor Address companyAggicI tatetanua name 5 phone must match ___________for R ______rel_ dtlme d T Owners Name 1,. pax,_ • a. • Giallo • Site Address Ti • a ; •I t• Date 1 •a►•. Phone q/ 43z$17 Directions to fob site from Ludington .. . . •• 1 O!► • ;rzo,i, 1 Subdivision 21113( = . 1 all Lot Descnpbon of Proposed Work �Q S�C� Heated SF3�Ot2 Unhealed SF '"L Finished Bonusm'+ #Sfacer\his Roo _ nto Crawl Space YPx Slab An General Ga trocar Intormebon xlf 1 ewlding Contractor s Company Warn* _9 f9- 724-�K1(.[,-/919-1•IY-$5'�9 to W. (bin 1: pa & scn Y7S7)'1 Telephone AddressEmatAddr&Addrk�e,_G .�-y=,!---`1« s.ravl --.5.14%2•______ Address license# Description of Work $etvlm pe OC)Amps T-Pole )(Yes No gole1al. 1ocor Eicark _919-30. — o2(4 Ekotnca}CanbaMas company Name Tela ns t t 2D �.rma Ar Nc- 27639 a Address 1 x7 E i �.IMctb. - can 2y 986 License it MtginglgaPargauggiguatentago DesmpsmofWork tJ .J Elsc+tvic. ?ri.Cwvara „1/ W mer 404-Rome A rrnnalco H Alf r:,nrt;Linn''3 Telephone q 7til /�Aysc��banKalConJtactors na�1nye�N�am�e �1 / �n L ,X1 �T9-Q ot6 R4, -n�jr� 11010 �Ml _ riC[Gilr �_ool 1 Address - lVY'I EmaY Addras Ltrora# Daeorpbon olWait t 4lurnbtrn aoadts 3.5 *rllr, lnbll TtarhbirA, ___ ___ Plumbing Comrecom ra Companma Tekpflone mamas tainstom s- Gaten5Eor4 OC27405 171 `" "^°del Lsxroe N i thalaharafkOkagiatgabla a •ai es uv • '� r . Insulappn Con, .. . , , Address � 3, AIC phone 2-q0�0 i.femme e! /1472 c� 27(,03 Talahons 'NATE 7Qr1/p ,141 41/lN /eve �✓'� General Contractor fill out end sign the second page of this spelt-soonj 3! I hereby certify that I have the authonty 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 that tw amino below I hays obtained all subcontractors permission to obtain these permits 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-y6eMonths to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee is a• •-r current fee • 0(/// S /l0/I7 -r ontractor icer(s)of Corporation Date Affidavit for Worker's Compensation N C G 8 87-14 The undereigned applicant being the `x/General Contractor _Owner _Oryicer/Agent of the Contractor or Owner Do hereby confirm under penalties of penury that the person(s) firm(s)or corporation(s)performing the work set in the permit Vas 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 workers compensation insurance prior to issuance of the permit and at any time dunng the permitted work from any person firm or corporation carrying out the t work ` 1 Company or N= s e C'rkxr c-r_a,- t on c, OC NC)/lit, I L 4' Sign w/Title I I .-i Al I Co dsronb� l noCakruP4)) 0 (0(1 / ate ACti SCHUM•l OP ID:AK CERTIFICATE OF LIABILITY INSURANCE °"T""""°"""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PROOUCER Maconachy-Stradley Insurance x°eile�cT AnnmaHe King 3205 Bretton St.NW Suite 100 PHONE En1,330-966-5170 North Canton,OH 44720 �y_ap 11A No): 330.986-1075 _ Robert D.Stradley ADDRESS:annmarieebmsinsagency.com INSURER(S)AFFORDING COVERAGE � NAIC0 1 INSURED Schumacher Homes of _ INSURER A:Cincinnati Insurance Co 110577 North Carolina Inc INSURER B: 2715 Wise Ave NW INSURER C: _ Canton,OH 44708 INSURER D- - INSURER E' INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS IS TO CERTIFY THAT 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - -. - - _ LTR TYPE OF INSURANCE INSRA6E8 n POLICY NUMBER IMMIPDYGYYYI IMMNDYIWYn LIMITS GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 A XI COMMERCIAL GENERAL LIABILITY CPP0890539 01/01/2017 01/01/2020 PREMSF uanceL $ 500,000 1 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY I $. I,OD6.09B GENERAL AGGREGATE ' $ 1000,000 GEHL AGGREGATE LIMIT APPLIES PER. - - 0 PoLICY'PRO LOC PRODUCTS-COMPIOP AGG $ 1,000,000 $ AUTOMOBILE WBNtt COMBINED SINGLE LIMIT A X_ ANY AUTO CPA0880539 rBO(Ea scoderU -i--$— _ � _ 500,000 ALL OWNED 01/01/2017 01/01/20181 BODILY INJURY(Per persml $ IFAUTOS LEO BODILY INJURY(Per eccden1) $ AUTOS ADIOS HIRED AUTOS 'NONOWNED - I- AUTOS PROPERTY DAMAGE $ (PERACCIDENTI • X UMBRELLA UM I $ OCCUR EACH OCCURRENCE I$ 3,000,000 A 1 EXCESS LIAa I CLAIMS-MADE CPP0890539 01/01/2017 01/01/2020 AGGREGATE $ 3.000,000 OEO RETENTION$ WORKERS COMPENSATION $ ANDEMPLOYERS'LIABILTY Y/M X WAY LIWC AMITS .TH- A ANY PROPRIETOR/PARTNER/EXECUTIVE WC2138802-02 01/01/2017 01/01/2018 T. 1,000,000 OFFICER/MEMBER EXCLUDED? NIA EL EACH ACCIDENT {Mandatory In NH) E.L DISEASE.EA EMPLOYE $ 1.000,090 If yes.,describe he„ q DESCRIPTION OF OPERATIONS below EL.DISEASE.POLICY LIMIT I$ 1,000,000 IN/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,II mon pace le required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ee" INFORMATION ONLY e... ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Robed D.Stradley ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ACCORD" SCHUM-1 OP ID:AK CERTIFICATE OF LIABILITY INSURANCE DATE MM"D^TMG 01/05/217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder la an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endoraement(s). PRODUCER CONTACT Maeonachy-Stradley Insurance NAME_Annmarle King St.N W Suite 100 PHONE 330 North Canton,OH 44720 Ar,NP-EN -9 L 88-5170 _—' FAX 3205 Bretton Robed D.Stradley oneae:anomer) _ INC,NO 330-9613-1075 egSmslnsss ency.com INSURER(S)AFFORDING COVERAGE NAICIP INSURED Schumacher Homes of - - - INSURER A:CIOC1008N Insurance Co 'I 0877 North Carolina Inc INSURER B: t —. — 2715 Wise Ave NW INSURER C t — — — Canton,OH 44708 INSURER o — I — — - INSURER E' — { —- INSURER F: COVERAGES -- — — CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBRAT- _ LTR TYPE OF INSURANCE ADDU IJ5R1 — POLICY EFF - POLICY EXP S1 R WVO POLICY NUMBER IMMNOryYYYI IMMNDM/YYI OMITS A XERAL LIABILITY COMMERCIAL GENERAL LIABILITY CPP0880539 EACH OCCURRENCE -DAMMGFr6RENTE6 _ _ 1,000,000 Dvov2olT ov0vz0m MED EXESrEeaeaeronj $ 500,000 HI L �culMs.AvoE �IoccuR IMED EXP IAny one person) 1,000 r I- - I PERSONAL a ADV INJURY 1$ 1,000,000 r. 1_ I GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1,000,000 -1 POLICY P I ZIT I -I LOC PRODUCTS-COMP/OP AGG $3 1,000,000 AUTOMOBILE LIABILITY ICOMBINES SINGLE LIMIT A XIANY AUTO CPAOBB0539 LIEa Waldena IL 500,000 4' X ALL OWNED f--I SCHEDULEp Oi/0112017 01/01/2018 BODILY INJURY Per Person) $ — — - I INREDAUTOS I NOT9WNEp BODILY INJURY(Po,°¢IEeni) $ PROPERTY DAMAGE jPER ADDEND � $ — i•X I UMBRELLA LIAR I OCCUR L$ A EXCE98 LMa M4DE DPPOB9O$39 I-EACH OCCURRENCE I$ 3,000,000 _LE I CLAIMS= 101/01/20111 01/01/2020 DED I I RETENTION$ AGGREGATE_ _ E 3.000,000 WORKERS COMPENSATION E$ - EMPLOYERS'LIABILITY STORY LI WC IMILS I .071-1- AND A 'ANY PROPRIETOR/PARTNER/EXECUTIVE Y'N 1 WC2138502-02 01/01/2017 01/01/20181MandatOFFICEory In 1X41 EL.EACH ACCIDENT g 1,OOD,000 IManCERJME NH) Il an ato In NH) E.L.DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTIONCF OPERATIONS below I EL.DISEASE-POLICY LIMIT I$ 1,000,000 NM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES CAIN ACORD 101,Additional Remarks SOeJuI&If more spate Is rewind) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ""INFORMATION ONLY"" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Robert D. Stradley @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD