BUILDNG ' Each section below to be filled out Application # [a 5 '9 2 K l4
by whomever performing work. Harriett County Central Permitting
Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910 -893 -7525 Fax 910- 893 -2793 www.harnett.org/permits
name & phone must match
Application for Residential Building and Trades Permit
Owner's Name: I-o ~ \•- \\ Date: 12- in -
Site Address: 5b 4 2 -&\ca. C3 r. 5p- z,, l. ."- 1,7% Phone: 1 /e cl -59oo
Directions to job site from Lillington: 1 1_ .t.,...._ L' ■
a't/J,.y e.— GJ,n e4 -A.
Subdivision: p Lot:
Description of Proposed Work: R'ep..: c F • r c - 1 ,� -vnaq 7. # of Bedrooms: ?
Heated SF: 10'1 S Unheated SF: Finished Bonus Room? Crawl Space: ✓ Slab:
/� General Contractor Information
f l&? it SS:.1f) (-IO t_ Cn ✓C_ in 1 '11 a ! - X3 cf - GS z?
Buildins Contractor's Company Name Telephone
eo 2, „ 1Z� 1: «t )y /Jr , `7 S ,,/s )04--e. Ow lts iner n .(-42
Addresses / Email Address
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Signs re o f Owner /Contractor/Offi&er( Tof Corporation License #
Electrical Contractor Information /
Description of Work R. /0,,,c_i -: 1-0 it- - 'Rm. t .. » Service Size: zo) Amps T -Pole: ✓Yes No
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Electrical Contractor's Company Name Telephone
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Address Email Address
Signs ur 4:72___
e of Ow r/C ntractor /Offtcer(s) of Corporation License #
Mechanical/HVAC Contractor Information
Description of Work C tars 4.t..•• . + - - Da
op • -C 'lo-e-, -1 fe S 3
Mechanical Contractor • - .m . any Name Telephone
_iq 53 otc4 5A„ ed ` K3
Add -ss Email Address
Signatu = '+Owner /Contractor /Officer(s) of Corporation License #
n r Plumbing Contractor Information
Description of Work 0-e f t t Fly L"-es r Lime_ e be , n - c 4,5+ . # Baths I
C- YIer 1 'i ✓w 4,i...s, Ai to-''SI- (fil
Plumbing Contractor's Company Name Telephone
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Address Email Address
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Sig ature o'6' ner /Contra 'fir /Officer(s) of Corporation License #
Insulation Contractor Information
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Insulation Contractor's Company Name & Address t✓twlc/f AIL Telephone
D- '7 Se/ L ii 3
*NOTE: General Contractor must fill out and sign the second page of this application.
u h o, r 1 oft 12/ lc
esrcicn, ml . ui?pm�i RppRe? tun
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you qualify for peril 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 Hamett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and if ai( 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 curr;' t fee s hedule i
/aG� 11 -- --- )0 —%
Signs ure 4 Owner /Contractor /Office of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 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 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 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. J
Company or Name: 0 r < s 5 r,- ( Q / r � `r'v" I ` r / CO- v t. , Le
Sign w/Title: 4 /_I G tvtt v3 l.f)
( wy -1i rrtt✓ Date: )2-- i
2esiden6ai B Application -' 'ii
. recorded moil b:
' 0 - 7. F. s DRAWN BY:
S. WINE, ATTORNEY
71 B , . DRIVE + 251 N. MAIN STREET
- �WINSTON- SALEM, NC 27155 Penn le /OR RRlrNI m s or Dun &atlas ': 4111 .,I S r . 9 a 1�B8 pt:;II0010�riie . es 1 &b8- 70019921
STATE • ' • • ' mom
: '� count
'ride Deed, ado MARCH , 100[ , by aedbehaves AnthonyJ. Frincipi
*Secretary o)' Veteran ; , . • united States of Arrr ca, wire address is Depoiment of Venoms Affairs,
Washington, Di n of of • s • r , ,, ,1 the CHIEF, PROPERTY MANAOHMBNT ,
JERRY R. F,,.. called Grantor, and
ROOBR F. HALL ' '' p
of the meaty. of , % CI ' , ' T "•,i r ate ' C $ +� Notch Carolina hereinafter called Orsotee(s):
Sizt none • , •
(3 6100000 ), secured by a D ramrded herewith, the receipt of which is
acknowledged, hereby 6nda, bergaiae, rah, • • y - : unto the -. , a . - - s), and the hrdrs or socoeseom and assigns of
said Oredee(s), that oerWn peed of land, in Coady, State of NORJ?I CAROLINA, and
which io described as follows:
pm 01- 0514-0475
.(:/;)
SWIM THE SAM PROPBATY DESCRIBED IN .t. .- . iiii;;. •,
Being the mess property described is a dated ocroBER 15, 2000 from
13. DAVIS OR FRANCIS '. ltiuetee
to the Semetary of Veterans Affairs, recorded in the Office of • .. • ' .. •• HARNETT County, Norm
Caroline, la Book 1447 , Page 636637 • This property is being ... - s ' ,. re*Mctve oovemde, amsemeds
and righm of way of record.
TO awe AND TO ROWS I odlorift dboLg oporly sad aU .: ' A - Warms Wombs, to ea
said Ormee(.), and the halm or stemma= end signs of add OnmeK4, fount, . r „ , fRWNW sad his
sacraments in such office, aft such, oovemnm with the add Grantee(s) and and midges of said
Ontatee(s), that the Orantot ie seized of laid premises in fee, and leas Oa dgM to . .' the same am free and
clear and that Orator will warrant and defend ms said title to the same against Oa • • i claiming by,
through or under Grantor
IN WITNESS WHEREOF, Omotor, on the day and year first above written, ham . • . • . - . , - , to be lined
and name and o nnd, qualified by � undersigned c acting pursuant ' PROPERTY 5U and 3720 of 1 Section
daft Y ,o.... ' actlng
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