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BUILDING APP 09/09/11 Application# Harnett County Central Permitting 11— so O t t G J t_ EaM section below to be filled out PO Box 65 Lilbngton NC 27546 by whomever performing work 910 893 1525 Few 91a Baa 41gJ www Ninonorg/pertnia Must be owner or licensed convector Address company Application for Residential Building and Trades Permit name B phone must match Owners Name I k`tMc((��l:12.1a.c- tt� Pv C BSc Date Site Address SSRIL` QctC -pA/ ,(•pp t� `, - PhoneC�V'�p �4 �a Directions to Job site from Lillington 'l_. Subdivision Lot Description of Proposed Work ('}f ' tyy\__ nnnt0i #of Bedrooms r3 Heated SF Unheated SF Finished Bonus Room9 Crawl Space _Slab !� General Contractor Information1``GV on (2-orc n1\14 move PJ ct4115—C.c:00 Building Contractors Company Name Telephone 3' Ntr 1-1—Lout SS-1. S SoNbrd tV4 Address Email Address 0c7 License# El- trial C•. rc •rl • io Description of Workhbf`S Lf) - -"1 Service Size %QJ Amps T-Pole _Yes No Electr : Cont - tors Com•any Name Telephone i --• � • � Email Address sdss tot. srU License# MamnicS/HVAC Contractor Information Description of WorkM +S- r 0 lb girlr q �,' Mechanical Contractor Company Nam: Tae ion ikP Addre s Edlai Atltlress ase# License# y-�V Plum�b�rnla Cor$ractor Information Description of Work chernol Seµi�/ 'FP,v -trLlA0Baths �-- -r G Plumbingt�for s Co pany Na z Tal p A^ �� a _ 't�[Pss 1 E Emil Atldress License N In/sulat Contractor Information Insulation Contractors C pa Nam & ddre Telephone *NOTE General Contractor must fill out and sign the seyond 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 in*Janina below I have obtained all subcontractors permission to obtain these permits and if my 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 : changes EXPIRE r .ERMIT FEE -6 Mo the to 2 years permit re-issue fee is $150 00 After 2 years re-issue fee is as per u rent fee sch.dule a 'els L ( 7 Sig - ire • owner/Cont' •r •fticer . o Corboralion Date Affidavit for Worker's Compensation NC GS 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 fort 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 al any time dunng the permitted work from any person firm or corporation carrying out the wo , Company or Nam:I Sign wliitle S . _IMAM i. Date / / i Effective Date: 07/05/2017 NORTH CAROLINA MODULAR BUILDING SET-UP CONTRACTOR LICENSE BOND # 3365629 WE, EJ WOMACK ENTERPRISES, INC DBAi RAVEN ROCK MOBILE HOME MOVERS as principal, located at 3335 NC HWV 97SANFORD, NC 27332 and ureTec Insurance Company - --- (surety)of 1330 Post Oak BlvdSte 1100 Houston, TX 77056 (address)a corporation incorporated under the laws of the State of Texas and duly licensed to transact a surety business in the State of North Carolina as surety, are indebted and bound to the HARNETT COUNTY (city or county inspection department)in the sum of five thousand($5,000)dollars for which payment we bind ourselves and our legal representatives jointly and severally. THE CONDITION OF THIS OBLIGATION IS SUCH, that whereas the principal has entered into a contract for the set-up and installation of the modular building described herein; NOW, THEREFORE, if the principal and all his agents and employees shall set-up and install said modular building in compliance with the regulations of the North Carolina State Building Code governing installation of modular buildings, then this obligation shall be null and void; otherwise, it shall be in full force and effect. It is expressly provided that: 1. This bond is executed by the said principal and surety to enable the principal to set-up one North Carolina labeled modular building. 2. This bond is in full force and effect as to the above State Building Code obligations of the principal for the set-up of one North Carolina labeled modular building at the following address: Street 524 RAFTER CREEK LANE _ City SANFORD___ North Carolina 3. This bond will remain in full force and effect for one year following the issuance of the certificate of compliance for the modular building. 4. The bond must remain on file with the HARNETT COUNTY (city or county inspection dept.), 5. The owner of the modular building described in paragraph 2, who sustains any loss or damage by reason of any actor omission covered by this bond may, in addition to any other remedy that he may have, bring an action in his own name on this bond for the recovery of damages sustained by him. 6. It is further understood and agreed that this bond shall be open to successive claims up to the face value of the bond. The surety shall not be liable for successive claims in excess of the bond amount, regardless of the number of claims made against the bond. In Witness Whereof, the above bounden parties have executed this instrument under their several seals, this the 5being hereto affixed and these presents duly signed be its undersigned name and corporaterepresentative, seal of each corporatetyparts t dayof JulL_ 2017 _ purs rsigned t to authority of its governing body. ^/ Signature of Principal ice'---C st .m SureTec Ins c: •ompa ,a Title Surety by .r _ S._ (signature) David Gonsalves (printed name) Title Attorney-in tact_ Address 1330 Post Oak Blvd,Ste 1100 Houston, TX 77056 35wPANC ` WO% ♦, q\\c VAT Day d Geese es N.C. Resident Agent '�\ t Power of Attorney Attached J4045 Ballantyne Corp PI.Suite szs,Charlotte,NC 28277 Address POA a:3365629 SureTec Insurance Company LIMITED POWER OF ATTORNEY Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make,constitute and appoint David Gonsalves its true and lawful Attorney-in-fact, with full power and authority hereby conferred in its name,place and stead,to execute, acknowledge and deliver any and all bonds,recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for: Principal:w WOMACK ar TEapR sES,INC BBA:RAVEN ROCK MOBILE HOME MOVERS Obligee: State of North Carolina Any City/County Amount: $5,000.00 and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President, sealed with the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises. Said appointment is made under and by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: Be it Resolved, that the President,any Vice-President,any Assistant Vice-President, any Secretary or any Assistant Secretary shall be and is hereby vested with MI power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company, to execute, acknowledge and deliver,any and all bonds,recognizances, contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be It Resolved,that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached, (Adopted of a meeting held on 20" of April, 1999) In Witness Whereof,SURETEC INSURANCE COMPANY has caused these presents to be signed by its President, and its corporate seal to be hereto affixed this 6th day of April, A.D.2017. U3AN0 SURETECCOI '-NY 4xx ....v eco hr 9 \v By: w e John lCno.�.,Prwid, t State of Texas ss: �\^1 County of Hams On this 6th day of April,AD.2017 before me personally came John Knox,Jr.,to me known,who,being by me . ly sworn,did depose and say,that he resides in Houston, Texas, that he is President of SURETEC INSURANCE COMPANY, the company descn.ed in and which executed the above instrument;that he knows the seal of said Company; that the seal affixed to said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Company;and that he signed his name thereto by like order. - J NoCQUEbYN BRE TEAS / /) /� n�� =%PS Public. Texas' Comm.Expires 0618.2021 V Notary ID 123903029 Ja uelyn Greenleaf,Notary Public My commission expires May 18,2021 I,M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,executed by said Company,which is still in full force and effect; and furthermore,the resolutions of the Board of Directors,set out in the Power of Attomey are in full force and effect. Given under my hand and the seal of said Company at Houston, Texas this 5th day • Jul , 017 , A.D. y M.Brent :eaty, Assistant Se:retary Any Instrument Issued In excess of the penalty stated above is totally void and without any validity. For verification of the authority of this power you may call(713)812-0800 any business day between 3:00 am and 5:00 pm CST. 0 \ o• $ 2 : ! ! o - E — ! \ ©« , \ _I no PD ! % 5 \ h - ( ! _ ▪ { , ; < I - - _ | : \ \ ® � � CO �\ re _ � Z / ( / - . 2 - j , � ; | o — \n }a- '2 0 ( 14 ( § r■ } \ _ ( \ 0{ » k . I � a • 2 § ! } m Io. oc \ m { # y o o { n\ ({ ; 7 — \ \ an R } :ƒ ( + // 73 | f | _ f :;•-• 0.ro f ( i ! ® - r \ \ ) } \ \ k}!