DOCUMENTS 09108111 Application#,I
Harnett County Central Permitting in i t`F-O F5 9
PO Box 65 Lilhngton NC 27546
Each section below to be filled out 910 893 7525 Fax 910 893 2793 www hameti org/permits
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 8 phone must match
Owners Name Gary Robinson Homes, LLC Date 3/27/2017
Site Address 772 Briggs Farm Road Phone 910-401-5505 ext 226
Directions to job site from Ldlington
Subdivision Briggs Farm Lot 11
Description of Proposed Work Single Family Dwelling #of Bedrooms 3
Heated SF 1967 Unheated SF 641 Finished Bonus Room') X Crawl Space _Slab X
General Contractor Information
Gary Robinson Homes LLC 910-977-2562
Building Contractors Company Name Telephone
4140 Ramsey Street Suite 115 lauren.grhomes@gmail.com
Address Email Address
67530
License #
Electrical Contractor Information
Description of Work New Construction Service Size 200 Amps T-Pole x Yes_No
Buford Electric, LLC 910-818-0994
Electrical Contractors Company Name Telephone
948 Pan Drive, Hope Mills NC 28348 thomasdbuford@yahoo.com
Address Email Address
15109-L
License#
Mechanical/HVAC Contractor Information
Description of Work New Construction- Single Family
Chacco, INC 910-429-9939
Mechanical Contractors Company Name Telephone
PO Box 36037 Fayetteville NC 28303 910-488-0318
Address Email Address
2957 PH-1-3
License#
plumbing Contractor Information
Description of Work New Construction #Baths
Dell Haire Plumbing, LLC 910-429-9939
Plumbing Contractors Company Name Telephone
PO Box 65048 2503 Southern Ave, Fay NC 28306 accountingoffice@ncrrbiz.com
Address Email Address
32886-P-1
License #
Insulation Contractor Information
Cumberland Insulation 4205 Clinton Rd Fay, NC 28312 910-484-7118
Insulation Contractors Company Name&Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
I hereby certdy 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 that by signing below I have 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-6 • • to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is as p- curren -e -.-hedule
312 tI f -
Signs re of s, n-r/Contractor/Off er(s)of Corporation Date
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 penury 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
X 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 pnor
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. e Ga obinson Homes,// LLC ,1 ' L
Sign w/T e ,�, ,L Vf Y (1n%u Y1L Pro CtiACl Lav1 Date .3-211?
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