DOCUMENTS 09/09/11 Application#
Harnett County Central Permitting 11-500404 5
Each section below to be filled out PO Box 65 Lillington NC 27546
910 893 7525 Fax 910 893 2793 www hamett erg/permits
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 6 phone must match 1 �1
Owners Name --. _Dc..--/ Cl _Ju \4 L
-5 Date ot\, `
Site Address \nock KGven VocY-, "P-a PhoneQl9--l4lo-MIL
Directions to lob site from Lillington LA.al i rvc1 '54-t€ud Pwvont. 8 . V-e_S
KA:3K- - ln-FD Qus Qark P d q.3v ox L nitt kc Qv&F S
-6l •
Subdivision Lot
Description of Proposed Work (ST YY011.4 nruttrkt34pd #of Bedrooms 3
Heated SF Unheated SF Finished Bonus Room? Crawl Space Slab
General Contractor Information
J
o.)Pv\-- cJL YYu-t McJe1S Cllq --1-15-3/.00
Building Contractors Company Name Telephone
;5335 N L lr1,_.L.t.t K"1 Sid >J ( -6\
Address �i33 .L Email Address
.2)Uoo
License#
Electrical Contractor Information
Description of Work ttrAC Lp lAeCktC Service Size 20.)Amps/ T-Pole _Pest No
CrOVN t11 �SQMY 1 c. Oil( mLl'1--rcn
E ctrical Contractors Companame Telephone
reCiTh V Qe--F &r d N I A
Addres6� 283 i5 Email Address
License#
. Mgchanical/HVAC Contractor Information
Description of Work- t Al •ye iII
nllcxt A°t r fl l.c _ aln-qui-nn0-1
Mechanical Co rrtractor sA Company Nandi coil\ I [' Taleph(ne.
A.. , v1 �`lC
Email Address
License#
Plumbm Con raact�or Informationfo� �7
Descriptign of Work \\€XV. uQ �SeaDC #Baths -
'J'h tc\ ms Q\cx --lglD- p'ic15
Plumbing Contractors Company Name Telephone
i t ..4 A a !tel ISI SS— l • )0I A
GA,dd�ddresss S[_ 'a1 _(p Email Address
License#
stn 1 Insulation Contractor Information fy, (//�\
Insulation Co or s Com any ame&Address Telep e
*NOTE General Contractor must fill out and sign the second page of this application
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 that by signing below I have obtained all subcontractors
permission to obtain these permits 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 all changes
EXP D PERMIT FEES • the to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is a current -. sche' .
i
Sign re of Owner/Contractor/Of icer(s)of rporation Date Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the /
General Contractor Owner 1/ 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 h 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 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 work
Company or Name 90k).1:24.\/I 90k).1:24.\ % Yh 1 t j VYbJ SV
� S
Sign w/Tttle ;/1r_, Date `-A G‘ I/u2 , I /
DO NOT REMOVE!
Details: Appointment of Lien Agent
Filed on: 04f26f2017
Entry #: 641853 Initially filed by: countryfairhomes
Designated Lien Agent Project Property
Print & Post
I mi Amsuicun Title Illnlnmcu('ompaii) lel AS
191)9 raven lock id �" 0
unnna ass..I leiwne cons Lillington.NC 27546 _ ' rnll :
address:N W.HarPwSi. r.i SSusiRaleleb. MIti oMl,
4
. 11
Vt Bleu! Mr -
Pnnnr:xxran+F)tv Property Type Contractors:
Picaic post this notice on the lob Site.
tnth wntoi.ce .na. 1-2 Family Dwelling Suppliers and Subcontractors:
Scan hllx Linage with your Ian plums.to
stew this fling-You can then file a Notice
Owner Information to Lien Agent lot this Prulcct.
dustin lone"
5209 mirror N
fuquay-%Anna N( 27526
United Stales
Email oubm20 1,n gmad corn
Phone 919-796-005
Via,Comments t111
rahnical Support'hotline:0064)690-9184
Effective Date: 04/06/2017
NORTH CAROLINA MODULAR BUILDING
SET-UP CONTRACTOR LICENSE BOND
# 3364669
WE EJ WOMACK ENTERPRISES INC DBA RAVEN ROCK MOBILE HOME MOVERS as principal,
located at 3335 NC HWY 87 SANFORD, NC 27332 _
and SureTec Insurance Company
(surety) of 1330 Post Oak BlvdSte 1100 Houston,TX 77056
(address)a corporation incorporated under the laws of the State of Texas
and duly licensed to transact a surety business in the State of North Carolina as surety, are indebted and bound to the
COUNTY OF HARNETT (city or county inspection department)in the sum of five
thousand ($5,000) dollars for which payment we bind ourselves and our legal representatives jointly and severally.
THE CONDITION OF THIS OBLIGATION I5 SUCH, that whereas the principal has entered into a contract for the
set-up and installation of the modular building described herein;
NOW, THEREFORE, if the principal and all his agents and employees shall set-up and install said modular building in
compliance with the regulations of the North Carolina State Building Code governing installation of modular buildings, then
this obligation shall be null and void; otherwise, it shall be in full force and effect.
It is expressly provided that:
1. This bond is executed by the said principal and surety to enable the principal to set-up one North Carolina labeled
modular building.
2. This bond is in full force and effect as to the above State Building Code obligations of the principal for the set-up of
one North Carolina labeled modular building at the following address:
Street 1909 RAVEN ROCK RD
City LILLINGTON North Carolina
3. This bond will remain in full force and effect for one year following the issuance of the certificate of compliance for
the modular building.
4. The bond must remain on file with the COUNTY Of HARNETT . _ -. (city or county inspection dept.).
5 The owner of the modular building described in paragraph 2, who sustains any loss or damage by reason of any
act or omission covered by this bond may, in addition to any other remedy that he may have, bring an action in his own
name on this bond for the recovery of damages sustained by him.
6. It is further understood and agreed that this bond shall be open to successive claims up to the face value of the
bond. The surety shall not be liable for successive claims in excess of the bond amount, regardless of the number of
claims made against the bond.
In Witness Whereof, the above bounden parties have executed this instrument under their several seals, this the
7th day of April 2017 the name and corporate seal of each corporate party
being hereto affixed and these presents duly signed be its undersigned representative, pursuant to authority of its
governing body. --
,.( �� Signature of Principal
ITNISureiec Insu c ompa Title
Surety by
(signature)
David Gonsalves
_..
(printed name)
Title Attumeytin-(act
Address 1330 Post Oak Blvd, Ste 1100 Houston,TX 77056
N.0
77Resident Agent David— (;onsa e
14045 Ballantyne Corp PI,Suite 525,Charlotte,NC 282
Power of Attorney Attached =% Address
POA a: 3364669
SureTec Insurance Company
LIMITED POWER OF ATTORNEY
Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and
existing under the laws of the State of Texas, and having its principal office in Houston, Han-is County, Texas, does by these presents
make,constitute and appoint David Gonsalves
its true and lawful Attorney-in-fact, with full power and authority hereby conferred in its name,place and stead,to execute, acknowledge
and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the
conditions of contracts and consents of surety for:
Principal: E WOMACK ENTERPRISES INC DOA RAVEN ROCK MOBILE Notre MOVERS
Obligee: State of North Carolina Any City/County
Amount: $5,000.00
and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President, sealed with the corporate
seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney-in-Fact may do in the
premises. Said appointment is made under and by authority of the following resolutions of the Board of Directors of the SureTec
Insurance Company:
Be it Resolved, that the President, any Vice-President, any Assistant Vice-President, any Secretary or any Assistant Secretary shall be and is
hereby vested with full power and authority to appoint any one or more suitable persons as Attomey(s)-in-Fact to represent and act for and on
behalf of the Company subject to the following provisions:
Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company,to execute, aclmowledge and
deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all
notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such
Attorney-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary.
Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or
any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid
and binding upon the Company with respect to any bond or undertaking to which it is attached. (Adopted us a meeting held on 20th of April,
1999.)
In Witness Whereof SURETEC INSURANCE COMPANY has caused these presents to be signed by its President, and its corporate seal
to be hereto affixed this 21st day of March,A.D.2013.
oAaN0 SURETEC . -'- OMPANY
111%jw x4i
9 S. By: ��
w`iw_I jgi John no x T., •resident
State of Texas ss: 7\ 1' ' /x
County of Harris
On this in st day on, exaAD. he2013 before me personally came John Knox E me known,who,being by me dulyd sworn,did depose and say,that he
resides in Houston, Texas, that he is President of SURETEC INSURANCE COMPANY, the company described in and which executed the above
instrument;that he knows the seal of said Company;that the seal affixed to said instrument is such corporate seal; that it was so affixed by order of me
Board of Directors of said Company;and that he signed his name thereto by like order.
JACQUELYN f Texas ADOStat
NELYN public
(\ Comm of 5M
�/ My mm.Exp 511B/2017 acquelyn Maldonado,Notary Public
My commission expires May 18,2017
1,M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is awe and correct copy
of a Power of Attorney,executed by said Company,which is still in full force and effect;and furthermore,the resolutions of the Board of Directors,set
out in the Power of Attorney are in full force and effect.
Given under my hand and the seal of said Company at Houston, Texas this 7th day of AAAAppriill//��/(//r/ 017 , A.D.
-Bret Beaty' Assistant S eretary
Any Instrument Issued In excess of the penalty stated above Is totally void and without any validity.
For verification of the authority of this power you may call(719)812-0800 any business day between 8:00 am and 8:00 pm CST.