DOCUMENTS 09109111 Application#
Harnett County Central Permitting 1 50D d 3 1 J
PO Box 65 Ltlhngton NC 27546
Each section910 893 7525 an belowto filled out work
Fax 910 893 2793 www harnen org/permits
by whomever performing tog be
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 8 phone must match
Owners Name ADMS $DCMMC41 lit Date JCIZZIa1-
Site Address 405D Old IAS 4L1 LitItn9-kr) NC Z1-54ta Phone 910-4oI—SSDS
Directions to lob site from Lillington Lei'} twi Old 4Z1 - Gro 2.1
Subdivision OICI u5 411 (1-ohna{hovt 'MAI lay- Tract) Lot
Description of Proposed Work Single- ramiti Dimulti ' #of Bedrooms
Heated SF 22'62- Unheated SF 5614 Finished Bonus Room/ VPS Crawl Space Slab
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 #
€lectncal 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
Chaco.), INC 910-429-9939
Mechanical Contractor s 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 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 Dv slanrna below I have obtained all subcontractors
permission to obtain these permits and if au 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 PE IT FEES-6 Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is as per ur ee schedule
5122I(9—
Signatu Owne/ContractorlOfficer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor _Owner V/ 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
VHas 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 Name Gary binsoonnJHomes, LLC l.,
Sign w1ride VP Ptairy ' c-1 t Date 51Z1
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