BUILDING 09/09/11 �A'`pppl�vicatiio�on# pp
Harnett County Central Permitting 1 ' Li oa
Each section below to be filled outPO Box 85 L IlmQlon NC 27548
t whomever performing murk 910 893 7525 Fax 910 893 2793 www hermitorg/pennib
Must be owner or licensed
contractor Addfess company Application for Residential Budding and Trades Permit
name&phone must math 1�� _
Owner a Name Cyt QIC ; , l t 6-01—S. Date I Si i '7
Site Address Cyt
leTh Phone
Directions to job site from Lillmgton
Subdivision Lot
Description of Proposed Work #of Bedrooms
Heated SF_Unheated SF Finished Bonus Room? Crawl Space _Slab
General Contractor Information
Building Contractors Company Name Telephone
Address Email Address
License#
glectncal Contractor Information.
Description of Work Service Size _Amps T-Pole _Yes No
Electrical Contractor s C par:, hone
Address Email Address
License#
Mechanical/HVAC Contractor IrNopnation.
Description of Work rte\_ Q,�
Mechanical Contractor Cq '[O Telephone
Address - \ Email Address
License#
plumbing Contractor Infomiatr
Description of Work aths
astiPlumbing Contractors Compan (((y\/ Telephone
Address ((((JfJ ` Email Address
License# l/
Insulation Contractor information
J a Y1n 1f—
Insu ton Contractors Company Name&Address Telephone
'NOTE General Contractor must fill out and sign the second pegs 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 tome and that pv martin 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 Months to 2 years permit reissue fee is$150 00 After 2 years re-issue fee
is as per current fee schedule
iwriGatioXi(r//Loam ^ ' 7
J amre of OwnOwner/Contractor/Officer(s)a Corporation ��
Affidavit for Worker's Compensation NC 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
covenng 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
CCompany or Nam9W14 (P
44CL J6t/
?Qv While pate yrril7
Application#
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546 - Ph:910-893-7525 - Fx:910-893-2793 - www.hamett.org/pennits
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner(s)of Structure: James Calton Williams Phone:9197957017
Owner(s)Mailing Address:128 rosea.Benson NC 27504
Land Owner Name(s): James Calton Williams Phone:919 7957017
Construction or Site Address:`4°
PIN# Parcel#
Job Cost: Description of Work to be done build house with detached garage and guest house
Mechanical: New Unit Wah Ductwork_ New Unit Without Ductwork_ Gas Piping V Other_
Electrical*: 200 Amp_<200 Amp ✓ Service Change_ Service Reconnect_ Other• _
For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap_ Number of Baths Water Heater
Specific Directions to Job from Lillinaton:
take 401 towanls fuquay vanna turn left on wilbum M first driveway on left
Subdivision: Lot#:
I James Carron Williams will provide the eleariral labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 12801° , which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code and all
other applicable State and local laws,ordinances and regulations.
Fowler and Sons Inc 9197794330
Contractors Company Name Telephone
105 meed rd suite 2 raleigh nc 27604 Cadtonwllliams128@gmail.com
Address Email Address
12801u
License# 1� , /`/���""
Structure Owner/Contractor Signature: (Co/74sr G(/`^yDate:
By signing this application you affirm you have obtained permission from the above listed license holder to
purchase permits on their behalf. If doing the work as owner you understand that you cannot rent,lease or sell
the listed property for 12 months after completion of the listed work.
'Company name,address, &phone must match information on license
Application#
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546 - Ph:910-893-7525 - Fx:910-893-2793 - www.hamett.org/pennks
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner(s)of Structure: James Canton Williams Phone:9197957017
Owner(s)Mailing Address: 128 rose C.Benson NC 27504
Land Owner Name(s): Jamas Canton Williams phone:919 7957017
Construction or Site Address:'b0
PIN# Parcel#
Job Cost: Description of Work to be done Mal house with detached garage and guest house
Mechanical: New Unit Wdh Ductwork iii New Unit Wthout Ductwork_ Gas Piping ✓ Other
Electrical': 200 Amp_<200 Amp_Service Change_ Service Reconnect_ Other• _
For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap_ Number of Baths_ Water Heater
Specific Directions to Job from Lillington:
take 401 towards fuquay varina turn left on wilbum rd first driveway on left
Subdivision: Lot#:
I James Canton Williams will provide the mechanical labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number Is ,which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code and all
other applicable State and local laws,ordinances and regulations.
Fowler and Sons Inc 9197794330
Contractor's Company Name Telephone
105 rupert rd suite 2 raleIgh nc 27604 Caraonwilliams12
B®9mail.com
Address Email Address
6622ph3
License#
Structure Owner/Contractor Signaturecfr ('41.4%771*�44 e Date:
By signing this application you affirmou have obtained permission from the above listed license holder to
purchase permits on their behalf. If do the work as owner you understand that you cannot rent,lease or sell
the listed property for 12 months after completion of the listed work.
*Company name,address,$ phone must match information on license
Application#
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 - Ph'.910-893-7525 - Fx:910-893-2793 - www.harnett.org/permits
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner(s)of Structure: James Canton Williams Phone:9197857017
Owner(s)Mailing Address:128 rose et.Benson NC 27504
Land Owner Name(5): James Canton Williams Phone:919 7957017
Construction or Site Address:440
PIN# Parcel#
Job Cost: Description of Work to be done build house with detached garage and guest house
Mechanical: New Unit With Ductwork New Unit Without Ductwork Gas Piping Other
Electrical•: 200 Amp_<200 Amp_Service Change_ Service Reconnect_ Other
•For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap' Number of Baths 5 Water Heater
Specific Directions to Job from Lillinaton:
take 401 towards fuquay vanna turn left on wilbum rd first driveway on left
Subdivision: Lot#:
James Canton Williams will provide the Plumbing labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 66226113 which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code and all
other applicable State and local laws, ordinances and regulations.
Fowler and Sons Inc 9197794330
Contractors Company Name Telephone
105 nmpen rd suite 2 raleigh nc 27604 Carltonwillams128Qgmail.com
Address Email Address
6622ph3
License#
o •
Structure Owner/Contractor Signature:) ( (;/, ?l' GJ4� Date:
By signing this application you affirm you have obtained permission from the above listed license holder to
purchase permits on their behalf. If g the work as owner you understand that you cannot rent, lease or sell
the listed property for 12 months after completion of the listed work.
*Company name,address,8 phone must match Information on license
STATE OF NORTH` CAROLINA OWNER EXEMPTION AFFIDAVIT
COUNTY OF c�1(�],,f`�p PURSUANT TO G.S.87-14(a)(i)
�^%' `• Inspection Department
Parcel Identification Number and address where the building is to be constructed:PIN OA.044 I - CS.W -.5'ga,0°0
Address LC; \ CisW n l24.1
Type of construction:residential 0 Commercial Dlndustrial 0 Other
Intended use after completion(e.g.Personal residence): ?trar�1 RA-Sid-Let Q
Building permit number associated with this application: % I SCIMt-t'i't S I
I, .Aire"5 CA27ta1W /j//4.4;i7ctl
(Print Full Name) -(9'/ ) ] ��- /7
(Phone Number))
hereby claim exemption from licensure under G.S.87-1(b)(2)by Initialing the relevant provision in paragraph 1
and Initialing paragraphs 2-5 below attesting to the following:
1.y/"" I certify I am the owner of the property set forth above on which a building is to be constructed or
(/altered and for which application for a building permit is hereby made;
OR
I am legally authorized to act on behalf of the firma corporation that is constructing or altering this
building on the property owned by the firm or corporation as set forth above:
(Name of Firm or Corporation)
2. (P I will personally superintend and manage all aspects of the construction or alteration of the building
and that duty will not be delegated to any person not duly licensed under the terms of Article 1,Chapter 87
of the General Statues of North Carolina.
3. itedl will be on site regularly during construction and I will be personally present for all inspections required
by the North Carolina State Building Code,unless the plans for the construction or alteration of the building were
drawn and sealed by an architect licensed pursuant to Chapter 83A of the General Statutes of North Carolina.
4. 4I understand that by executing this licensing exemption AFFIDAVIT pursuant to G.S.87-1(b)(2),I am
required by law to occupy the building for which the licensing exemption is granted for twelve months after
completion,� during which time it may not be offered for rent,lease or sale.
5. _—I understand a copy of this AFFIDAVIT will be transmitted to the North Carolina Licensing Board for
General Contractors for verification I am validly entitled to claim an exemption under G.S.87-1(b)(2)for the
building construction or alteration specified herein. I further understand if the North Carolina Licensing Board
for General Contractors determines I am not entitled to claim this exemption the building permit issued for the
construction or alteration specified herein shall be revoked pursuant to G.S 153A-362 or G.S. 160A-422.
/
(Signature of Af lant) '/7
I ' (Date) r�
Sworn or affirmed and
ssy)bscritred before me this the 5 day of 20 I /
C ( tu Ilc) ----
'(}�C�/�`�� .,lp (Notary Stamp or Seal)
ted Berra of Notary pirblk�C _
(NOTE II Is a clean Felony to willfully comma perjury in any affidavit taken pursuant to NC G.S. 14-209)
Acknowledgement
STATE OF k[li
COUNTY OF liar RQ*. ,,.,,��
I certify that Parl-Vm G1. Wperssonally. appeared before me this day, acknowledging
to me that h or she signed the foregoing document l� FuMs�. rensamthen i o�
V ume or description of:maehed document
I further certify that(select one of the following identification options):
l I have personal knowledge of the identity of the principal(s)
I have seen satisfactoryevidenceevidence of the principal's identity, by a current st to or
deral identification with principal's photograph in the form of a
ea
A credible witness. , has sworn or affirmed to me the
items.d etemn.e„itnes
identity of the principal, and that he or she is not a named party to the foregoing
document, and has no interest in the transaction.
Date{ y *LU1T. ieti gr t foi_.
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N
S4'. rver NO;rzi y;:•A My commission expiresrk S- hi 20/4-
-Z. �T
April 4, 2017
To whom it may concern:
There are no borrowed funds being used for the construction of the house being
built at 540 Wilburn Road, Fuquay NC. This house is being built for James Carlton
Williams and Sarah Cashion Williams.
Notary