DOCUMENTS Initial Application Date:41ato ' i I Application# Ir-i sa--4i d JL )
CU#
COUNTY OF HARNETT RESIDENTIAL LAND USE APPLICATION
Centr I PQermitting/a•L�� 108 E.Front
SVeeet,tt,,1�L_illin�gtoonn,Vet27546 Phone:(910)893-7525 04:2 Fax:(910)893-2793 www.hamett erg/permits
IRELunDEO SUn Y MTTF`FIVISEERIO(ORFR TO PURCHASE)&SITE PLAN ARE REQUIRED WHEN SUBMITTING A LAND USE APPLICATION"
avnelt:'4ejory Lc L1�• ( ' I 1 Mailing Address' Ca.2 67 Me-Itter S/
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City: ��C /1� T sola: NC Zip:d750/ Contact /%-Y.tt-&730 Email:// P,9"
APPLICANT': :4. ,O ry _tom.C Mailing Address: L 2- 6 - i ' Z 4r- JT
City: W e State:N" Zip:.)7"/ Contact No: 9,1- Y22' Yh;OEmail':
'Please nil o applicant Information if different than landowner^ (, / ��
CONTACT NAME APPLYING IN OFFICE: „&Ch 1171: Dr✓/ Phone 9,°J -4/22- kr30
PROPERTY LOCATION:Subdivision: ��)) J�j// Lot#. .R Lot Size(: • La 9[,/^
State Road# '70 State Road Name: 7DU✓1 2I Map Book 8 Page: , �r / !S`c
ParcelQb/� � ELOCI Q b.-Aj 6 PIN: 06N at, -52 V?. 00 0 / q
Zoninglecit Flood Zone. k Watershed: Deed Book 8 Page: /2 Si 130/ Power Company': ']4%t ✓;ezg7 /q 1 rr S5
'New structures with Progress Energy as service provider need to supply premise number from Progress Energy.✓ V
PROPOSED USE:
e/,/ `� '/ y Monolithic
LinFD:(Size 3 3 x 9j )it Bedrooms: #Baths:.2 Basement(w/wo bath): Garage/ Deck:// Crawl Space: / Slab: Slab:
(Is the bonus room finished?()yes (_)no wl a closet?( )yes (_)no(if yes add in with#bedrooms)
U Mod:(Size x_)#Bedrooms_#Baths_Basement(wlwo bath) Garage: Site Built Deck_ On Frame_Off Frame_
(Is the second floor finished?( )yes (_)no Any other site built additions?(_)yes (_)no
❑ Manufactured Home._SW DW TW(Size x )#Bedrooms._Garage. (site built?_)Deck: (site built? )
U Duplex:(Size x )No.Buildings: No.Bedrooms Per Unit:
❑ Home Occupation.#Rooms: Use: Hours of Operation: #Employees:
U Addition/AccessorylOther'.(Size_x )Use.
Closets in addition?(_)yes (_)no
Water Supply: 1--- County Existing Well New Well OF of dwellings using well )'Must have operable water before final
Sewage Supply. New Septic Tank(Complete Checklist) )sting Septic Tank(Complete Checklist) County Sewer
Does owner of this tract of land,own land that contains a manufactured home within five hundred feet(500')of tract listed above?( )yes (•Too
Does the property contain any easements whether underground or overhead(✓(yes (_)no I I , 1
Structures(existing or proposed):Single family dwellingsnufactured Homes: Other(specify): O I d k
S xOl�
sr—P
Required Residential Property Line Setbacks:� /� Comments:
Front Minimum SS
7 / )Actual . Y 4'.— at- 0-e LO ay
Rear aS if/7
Closest Side D
N asUteUrurngr lot
Nearest
onn esamam e lot
Residential Land Use Application Page1 2 03/11
APPLICATION CONTINUES ON BACK
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON: 7 ie) NL/ c27 /,.t(l[7J- LOq 2 Y&.C7`�/
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If permits are granted I agree to conform to all ordinances a - laws of the State of North Carolina regulating such work and the specifications of plans submitted.
I hereby state that for--. ents are accura : . • .irect to the best of my knowledge. Permit subject to revocation if false information is provided.
��.�// .s /e?L— 79
Ign.. , reo Owner or•7,r's •r nt Date
"It is the ownerlapplicants responsibility to provide the county with any applicable information about the subject property,Including but not limited
to:boundary information,house location,underground or overhead easements,etc.The cobnty or Its employees are not responsible for any
incorrect or missing Information that is contained within these applications."'
"This application expires 6 months from the initial date If permits have not been issued**
Residential Land Use Application Page 2 of 2 03/11
HTE# ,Fce.... Hariictt County Department of Public dealth 2 3 0 9 2
PERMIT H 2_78!7 Operation Permit
0 New Installation 0 Septic Tank Q'Nitrification Line 2'Repair 0 Expansion
PROPERTY LOCATION: 70 /00.5 Rd
Name: (owner) j5a-1{-:.. '- c144r k SUBDIVISION LOT #
System Installer: / 4-kt T?u ac:., Registration #
Basement with plumbing ❑ Garage ❑ Number of Bedrooms 3
Type of Water Supply: 0 Community C3Public G Well Distance from well --S-C? feet
System Type: 4 Types V and VI Systems expire in S years.
lln accordance with table Val Owner must contact Health Department 6 months prior to expiation for permit renewal.
Thu incus Am bun minded m comphana with applicaWe North('mini General Ancon.Roles lot Sewage treatment and Wpnul,And ill melanins at the ImprortmenC Remi,and(mwu,uon wihmnm,
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PERMITCONDITIONS:
L Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule.1967.
III. Maintenance: As required by Rule .1961. Other
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet or additional operation conditions. maintenance and reporting.
IV. Operation:
V. Other
f i D-Bus ❑ Pump 9 Alarm ❑ H10Line ❑ PWR Line
fallowing are she spwiltcasions for the sewage dispasa syssem on the above captioned property.
Type of system: ElConventional 2 tither ^fin 4-b El F/0,-.1 Septic Tank: 6e.:14-:-)J4:.S gallons Pump Tank: /d 0 0 gallons
Subsurface Nn. of J exact length width of ✓ depth of
Drainage field ditches / of each ditch b G feet ditches -9 feet ditches le .2Y inches
french Drain Required: linear feet
Authorized State Agent—/r te-,,c/f Date 6/2774°01
NAME: l3•," .-per APPLICATION#:
/*This application to he filled out when applying for a septic system inspection.*
County Health Department Application for Improvement Permit and/or Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED,CHANGED.OR THE SITE IS ALTERED,THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. The permit is valid for either 60 months or without expiration
depending upon documentation submitted. (Complete site plan=60 months;Complete plat=without expiration)
910-893-7525 option I CONFIRMATION
Environmental Health New Septic SvstemCode 800
• All prooerty Irons must be made visible. Place "pink property flags" on each corner iron of lot. All property
lines must be clearly flagged approximately every 50 feet between corners.
• Place "orange house corner flags"at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed at/for Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the undergrowth to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• All lots to be addressed within 10 business days after confirmation.$25.00 return trip fee may be incurred
for failure to uncover outlet lid.mark house corners and property lines.etc. once lot confirmed ready.
• After preparing proposed site call the voice permitting system at 910-893-7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
confirmation number Given at end of recording for proof of request.
• Use Click2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
Environmental Health Existing Tank Inspections Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for inspection by removing soil over outlet end of tank as diagram indicates, and lift lid straight up (if
possible) and then put lid back In place. (Unless inspection is for a septic tank in a mobile home park)
• DO NOT LEAVE LIDS OFF OF SEPTIC TANK
• After uncovering outlet end call the voice permitting system at 910-893-7525 option I & select notification permit
if multiple permits, then use code 800 for Environmental Health inspection. Please note confirmation number
given at end of recording for proof of request.
• Use Click2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
SEPTIC
If applying for authorization to construct please indicate desired system type(sl: can be ranked in order of preference,must choose one.
II Accepted I-1 Innovative 1-1 Conventional (_) Any
1 Alternative I—I Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answer is"yes",applicant MUST ATTACH SUPPORTING DOCUMENTATION:
I_)YES I_QINO Does the site contain any Jurisdictional Wetlands?
I—IYES Icl NO Do you plan to have an imi _o _system now or in the future?
p
I/ITES II NO Does or will the building contain any drains?Please explain. fo5.4.b'e :n,
I -ires ( I NO Are there any existing wells,springs, waterlines or Wastewater Systems on this prproperty?y
I C
IVES 1 Neu Is any wastewater going to be generated on the site other than domestic sewage?
�
I_IYES 1NU Is the site subject to approval by any other Public Agency?
I YES I1 NO Are there any Easements or Right of Ways on this property?
IaePirES I—I NO Does the site contain any existing water,cable,phone or underground electric lines?
If yes please call No Cuts at 800-632-4949 to locate the lines. This is a free service.
I Have Read This Application And Certify That The Information Provided Herein Is True,Complete And Correct. Authorized County And
Slate Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am So y Res,/sible For The Proper 'entificalion And Labeling Of All Property Lines And Corners And Making
T ssibl. o �A •it" le Site Evalu n Can Be Performed.
—et' I/I' , — '/--74 - / 7
"OPERT I 'NERS O. O 41 GAL REPRESENTATIVE SIGNATURE(REQUIRED) DATE
10/10
09/09/11 Application# C
Harnett County Central Permittingt-j I "-- a JV
PO Box 65 Lillington NC 27546
Each section below to be filled out
810 893 7525 Fax 910 893 2793 www harnett org/perm its
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match -L 7 9
OwnersName <e Oiq r , Date s—/h 1�/
Site Address 79 4.tu�a Li Phone 9/9. V2a-113o
Directions to job site from Li,Omgton
Subdivision /1 / Lot
8
Description of Proposed Work ld Ale.) 4m1_ #of Bedrooms
Heated SF /155 Unheated SF io Finished Bonus Room') Crawl Space V----Slab
/7 General Contractor Information
4'40.n c_ 9/4 -5'42a-Ma
Buijding"Contfactors Company Name Telephone �q
a,_•2 e %Y, &
- - `tJ "Ia.;"Ia.; 1. t o.....Address Em Ad assss �
License#
,�/ , / Electrical Contractor Information
D scnption of Work/ t.° /4nt_ Service Size JODAmps T-Pole ✓Yes_No
')a f�e4lir/
/ -7t eho - 723 - 3ay2
Electrical Contr?ctor s Company Name Telephone
/oa ,,(%•//✓o. Ciee_k- Ln z /44,
Address �/ Email Address
.2Y1/1- 4—
License#
Mechanical/HVAC Contractor Information
Description of Work
P/Lv' uieA./ a.964 ,�� Vu9N-605?
Mechanical Contractors Comp Name Telephone
c/a Old SA-qq[ /4/ Ct<k
Address ✓ Email Address
License#
,e /Plumbing Contractor Information
Description of Work / r12 /✓/�al MKS#Baths 4
pal- flI, J Gl �rhhi 910- G.2Y12a3
Plumbing Contractors Company Name Telephone
Address Email Address
list& — [leo 1.
License#
Insulation Contractor Information
7.Dsw/zit T,.,- 9/9 - '72.2- 9000
Insulation Contractor s Company Name 8 Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
t 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 stoning below I have obtained all subcontractors
permission to obtain these permits and if a y 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-8 Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is as per current fee sch ule
1/45-7-
c Signature
—CSignature o Owner ont tor icer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
✓ General Contractor 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
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 during the permitted work from any person firm or corporation
carrying out the work
Company or Name
Sign w/Tltle . 4, 0 - ,u— Date ,c-A I�
I �
LIEN AGENT INFORMATION
Effective April 1,2013
In accordance with North Carolina General Assembly Session Law 2012-158,
Inspection Departments are not allowed to issue any permit where the project cost
is$30,000 or more unless the application is for improvements to an existing
dwelling that the applicant uses as a residence OR the property owner has
designated a lien agent and provided the inspections office with the information
below:
Name of Lien Agent //p37/3 —
Mailing address of Agent PO t,/rs,r,.&cr 0 H i7
Ch �l /4- Ill—_N NL 2 7515
Physical address of Agent
Telephone 'q t a- Fax- Fax Y<e-- `k 7— 2/KO
Email
The information will be attached to the permit record and a copy provided to the
applicant. The applicant is required to post a copy on the construction site.
Excerpt from North Carolina G.S. 160A-417:
"(Effective April 1,2013)No permit shall he issued pursuant to subdivision(1)of subsection (a) of
this section where the cost of the work is thirty thousand dollars ($30,000)or more, other than for
improvements to an existing single-family residential dwelling unit as defined in G.S. 87-15.5(7) that
the applicant uses as a residence, unless the name,physical and mailing address, telephone number,
facsimile number,and electronic mail address of the lien agent designated by the owner pursuant to
G.S. 44A-11.1(a)is conspicuously set forth iu the permit or in an attachment thereto.The building
permit may contain the lien agent's electronic mail address. The lien agent infomtation for each
permit issued pursuant to this subsection shall he maintained by the inspection department in the
same manner and in the same location in which it maintains its record of building permits issued."
www.liensnc.com
5/1/2017 Payment Receipt confirmation (A4
Payment Receipt Confirmation ✓�
J
Your payment was successfully processed.
Transaction Summary
Description Amount
Liens NC $25.00
H
Total Amount Paid $25.00
Customer Information
Customer Name Derek G Gregory
Local Reference ID 211899
Receipt Date 5/1/2017
Receipt Time 04:23:52 PM EDT
Payment Information
Payment Type Credit Card
Credit Card Type MAST
Credit Card Number 4065
Order ID 21655666
Billing Name Gregory Construction
Billing Information
Billing Address 62 E.McIver St
Billing City,State Angier,NC
ZIP/Postal Code 27501
Country US
Phone Number 9/94228130
Fax Number 919-639-7001
Mk receipt hes bone mailed to the aldms below.
Email Address Gregoryinclanman(a)gmail.com
Cregoryinclanman@gmaiLcom
https://securecheckcut.cdc.nicusa.can/CanmonChackPageReceipOFrm Receipt 12