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BUILDING
Application # 1,0 SOJ "z 75 Each section below to be flied out Harnett County Central Permitting by whomever performing work. PO Box 65 Lillington, NC 27546 contractor. or. Addreesss, , company www.hamettorg/permits Must owner or s 910 -893 -7525 Fax 910- 893 -2793 www.hameorg /permits name 8 phone must match (� Application for Residential Building and Trades Permit Owner's Nam :l.fIVIt..1 E• e \ft \me12 1 S / D / � ate: II\ b Site Address:t 04 I, to 61 IJ�\-�-2 R t7- \AIRr1.�1Q \ Lt r e. Phone: "1 \ D 6)- 1l . Directions to job site from Lillington:, -2 ' a-m 46 6 _ et-iA .z X, k 4- (2-6 P..-E \c r Q 1i h \c . (S--r� R\ L�.4 p\--p pro v 1 0\ , 1 Q O \ A LA-Jai a \ > 4"\ - i t..A LAI•) t Subdivision: ( C1- \ S k Rtt-q -- C e \ Lot: l Description of Proposed Work: S I P4 Q FA M t Ltd\ (Z QS 1 bRMc-c- # of Bedrooms: 3 Heated SF: 1 » q Unheated SF: Finished Bonus Room? 11 D Crawl Space: _ Slab: -V G eneral Contractor Information CLi 4-V7ti\ \Z1C NtriY\R-S 0k Prne fltkrs LLC- 0 11 Q 1 '1"1 b39'3 Buiidin Contractor's Company Name Telephone To 0 ox - Li liveS•-{- Ekb \ \ c an 3 L 6t rr Lc - 6 nc • R. la • cb rn Address Email Address Signature of Owner /Contractor / Officer(s) of Corporation License # Electrical Contractor Information Description of Work (\Q._ u..) (Q (f b 9 A 1 Service Size: De Amps T -Pole: A- Yes No 'i - Kt NS EIEc_k2 c\ la a 6 cz Electrical Contractor's Company Name Telephone . 3go\ .- ?6R -2L- 120 Pn atRlti 6 k R- \f\'c "c) 6mR kt_.z0 m Address r Email Address M . \ %%Ns 1 4 - S 1 ( - Signature of Owner /Contractor / Officer(s) of Corporation License # Mechanical /HVAC Contractor Information Description of Workllk-w `2S ( I ■ l \ c1 0 C.R -i2o \ \ (\ P. Cer- Y\C-n 0_-F R (Z rJC_.- R \ 9 SC U - 1 `I I \ Mechanical Contractor's Company Name Telephone 6f)-I r)-- \- U- A* 1 D \ S, \i\j¢ S- a. I A- v1tUYN �1u I, gi� 4L■ Email Address 2-- ° 1 0 - t 1 Signature of ner /ctor /Officer(s) of Corporation License # Plumbing Contractor Information \ D scription of Work 1 \ Q u 2 e S 1 1 L - (\• -\ p' }- b -Q. # Baths e. \g_ \ c QUA D\ --1 9 UK n\ \ I n ` N R \ 9 C u- 1C 1 Plumbing Contractor's Company Name Telephone " n0- 4w 1 tA AUNSu\(\fC -a( ed.ctUQL \s. A dress Email Ad ress &.1,;� Ca \1 ul - a s Signature oflOwner /Contractor / Officer(s) of Corporation License # n r _ Insulation Contractor Information R 1 b 4g b Insulation Contractors Company Name & Address f' Telephone *NOTE: General Contractor must fill out and sign the second page of this application. L es***) Residential Building Applicat 1 of 33 /10 Homeowners Applying to Build Their Own Home Please answer the following questions than 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 of 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 as 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 Hamett 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 current fee schedule. Signature of Owner /Contractor /Officer(s) of Corporation Date Affidavit for Worker's Compensation N.C.G.S. 87 -14 The undersigned applicant being the: General Contractor Owner k 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) ormore 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. k 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. Compan rN�me: LA�� °A\(,YL(C \ -t-).-.4 \I S b Pi n C \ VC( S el- L L Sign wit • �l l�� h u n4 / \� (� RJR Date: \\ 1/2—'11 l 0 Residential Building Application 2 of 2 03 /10 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID MG DATE(MM/DDYYYY) LANDM -1 11/19/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Pinehurst Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 1789 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pinehurst NC 28370 Phone: 910- 295 -1431 Fax:910- 295 -1246 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Builders Mutual Insurance Landmark Homes of Pinehurat, INSURERB LLC Attn: Aaron Garner INSURER C: PO Box 734 INSURER D West End NC 27376 INSURER E: COVERAGES 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 15 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR UML POLICY NUMBER POLICYEFFECTV POLTCY EXPINA IIUN LIMITS LTR NERD TYPE OF INSURANCE DATE (MMIDOY) DATE (MINDDIY1) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP00119678 06/16/10 06/16/11 PREMISES aam,renoe) $ 100,000 CLAIMS MADE X OCCUR MED EXP (Any one Person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 �GENL AGGREGATE LIMIT APPLIES PER . PRODUCTS - COMP/OP AGG E 2,000,000 - A I POLICY J LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea a Widen!) erd) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY (Per accident) $ NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AU OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ — 1 OCCUR I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WUSIAIU- CIH- WORKERS COMPENSATION AND TORY LIMITS I I ER EMPLOYERS' LIABILITY A 34238110 06/16/10 06/16/11 EL. EACH ACCIDENT $ 100000 ANY PROPRIETOR/PARTN CUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE S 100000 II yes, descnbe under SPECIAL PROVISIONS below E. L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT) SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION HARNETT SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 80 SHALL County of Harnett IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR PO Box 65 Lillington NC 27546 REPRESENTATIVES. wci • ACORD 25 (2001108) 6 19'/~Q © D CORPORATION 1988