DOCUMENTS 09/09/11 �"A�pplication#`1
Harnett County Central Permitting 5604I37(00
Each sechon below to be SHOE out PO Box 85 Lillington NC 27546
by whomever performing work 910 893 7525 Fax 910 893 2793 www hamett or9/pemmts
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 8 phone must match -{JfJB
Owners Name JknvLs YV1G -ts Date L012111-
SdeAddress 40Th Mid u542-1 Ll11ivighn h1 C. T1-54CP Phone gla4DiSSD r
Directions to job site from Lillington
Subdivision S Tz Lot
Description of Proposed Work #of Bedrooms 4
Healed SF 2314' Unheated SF ultg Finished Bonus Room/ /t10 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 #
Electrical 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
Chacco, INC 910-429-9939
Mechanical Contractors 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 2 'S
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 by sunning below I have obtained all subcontractors
permission to obtain these permits and if ay 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 re-issue fee is $150 00 After 2 years re-issue fee
is as per urrent schedule
/\--- u 14-4 (R—
Signatu Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The unersigned 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
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 1' -
Company or Name Gary Robinson,biinHomes, LLC lO"N,�-QNl X26 b Lins pt---, ---
Sign w/Tdle f�//�/ Y DateLeri- 7—
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