DOCUMENTS Initial Application Date: / I 1 6/I I Application# 19 SCOL-1. 16 CL3
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COUNTY OF HARNETT RESIDENTIAL LAND USE APPLICATION
Central Permitting 108 E.Front Street,Lillington,NC 27546 Phone.(910)893-7525 ext:2 Fax:(910)893-2793 www.harnett.orglpermits
"A RE RDEO SURVEY MAP, CORDEDtDEED(OR OFFER TO PURCHASE)&SITE PLAN ARE REQUIRED WHEN/ SUBMITTING A LAND USE APPLICATION"
LANDOWNER: r II1 f 1 k_ Mailing Address: (25-11f l/4eblvu'Q CA (ci
City: 5"I rod state44 zip,27332 Contact No: 91q 8'1128($' Email. lob;lir aJ r.Ma/K ?/rrlii�an
(�I, Domo. F .-a'c. '
APPLICANT': Phlfltn fl ,A.UC Mailing Address: aS $I i3rk✓heuar C4 4c/ p
city: Sit KR10-7 state:N( zip:273)1 Contact No:lig 9(1 -22(7 Email: rid " 47 /ff'FAk&Qted k l(Wt,
•Please fill out applicant information i1 different than landowner I' �`I (,(�I •7 L�
CONTACT NAME APPLYING IN OFFICE: ' I,111 /) �b U. flc Phone# �I l• o ' C� L6/� /�
PROPERTY LOCATION:Subdivision: /I, Lot#: �' Lot
�Sizze::JI -a• 7�ta-
State Road�# QC);CI State Road NNam/e,, o •. • ' ' I x�C S Map�Book&'PPaget:1:44 f a 1 /
Parcel'. �//0����3p "I57t�C CZ)) LO �y PIN: ,5/? - CY g" SO I eL .600
Zoning..LV•olDgflood Zone: I' Watershed: AP- Deed Book&Page: IA I.I 1 3 Power Company':
'New structures with Progress Energy as service provider need to supply premise nui6? " from Progress Energy.
PROPOSED USE:
Monolithic
O BED:(Size x )1f Bedrooms_#Baths: Basement(wlwo bath)._Garage: Deck:_Crawl Space: Slab:_Slab:
(Is the bonus room finished?(_)yes ( )no w/a closet?( )yes (_)no(if yes add in with#bedrooms)
O Mod:(Size x )if Bedrooms if Baths_Basement(wlwo bath)_Garage: Site Built Deck:_ On Frame Oft Frame_
(Is the second floor finished?(_)yes (_)no Any other site built additions?( )yes ( )no
❑ Manufactured Home:_SW OW TW(Size x )#Bedrooms:_Garage: (site built? )Deck. (site built?_)
❑ Duplex:(Size x )No.Buildings'. No.Bedrooms Per Unit:
❑ Home Occupation:if Rooms'. �, 'I Use: Hours of Operation:O #Employees'.
❑ Addition/Accessory/Other(Size' [z x I )Use: Closets in addition?(_)yes ( )no
Si cCefl-h& OnI y
Water Supply: County Existing Well New Well(#of dwellings using well )*Must have operable water before final
Sewage Supply. New Septic Tank(Complete Checklist) Existing 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 (_)no
Does the property contain any easements whether underground or overhead(_)yes ( )no
Structures(existing or proposed):Single family dwellings. Manufactured' � Homes: Other(specify):
Required Residential Property Line Setbacks:Q Comments: MOP' 1A SII el
Front Minimum 3S Actual 5l' ✓ �. A. a. >• ' • • = - /
Rear
Closest Side P7A sA
SidestreeVcorner lot_
Nearest Building
on same lot
Residential Land Use Application Page 1 of 2 03111
APPLICATION CONTINUES ON BACK
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON:
If permits are granted I agree to conform to all ordinances and laws of the State of North Carolina regulating such work and the specifications of plans submitted.
I hereby state that foregoing
g statements are accurate and correct to the best of my knowledge. Permit subject to revocation if false information is provided
.
!/� -au-rdr —T— l s--/7
Sign reo Owner or Owner's Agent Date
"It is the owner/applicants responsibility to provide the county with?ny applicable information about the subject property,including but not limited
to:boundary information,house location,underground or overhead easements,etc.The county 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
NOT FOR LEGAL USE
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NAME: ?1 `al 1 t p ��1.4 i`c APPLICATION#:
*This application to be 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 SystemCode 800
• All property Irons must be made visible. Place "pink properly 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 t 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 UDS OFF OF SEPTIC TANK
• After uncovering outlet end call the voice permitting system at 910-893-7525 option 1 & 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(sc can he ranked in order of preference,must choose one.
I { Accepted { } Innovative 1 } Conventional I—i Any
{ ) Alternative II 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:
(_)YES I I NO Does the site contain any Jurisdictional Wetlands'!
1IYES { I NO Do you plan to have an irrigation ystem now or in the future? -/
I'IYES I—I NO Does or will the building contain any drains?Please explain. A M i la.lt I talc),
I+IYES 1I NO Are there any existing wells.springs,waterlines or Wastewater Systems on this property'?
I_IYES I p NO Is any wastewater going to be generated on the site other than domestic sewage?
I_IVES i—I NO Is the site subject to approval by any other Public Agency?
1IYES I ,I NO Are there any Easements or Right of Ways on this property'?
IYI YES 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 Thal The Information Provided Herein Is True.Complete And Correct. Authorized County And
State Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am Solely Responsible For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site AccessiblesiSooTT[hat A Complete Site Evaluation Can Be Performed,
�PE Qey ERLL4°r -��E�
PRfPERTY N S OR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) DATE
10/10
STATE OF NORTH CAROLINA 17E 175
COUNTY OF LEE
LAST WILL AND TESTAMENT
1i Li s
OF w
DONNA S. HOLT _ 's
hp N
I, DONNA S. HOLT, being of sound mind, but considering the uncertainty
of my earthly existence, do hereby make, publish and declare this to be my
Last Will and Testament, In the manner and form as follows:
ITEM I
My Executor, or Alternate Executrix, whichever the case may be, is direct-
ed to pay all just debts owed by me at the time of my death, including taxes,
funeral expenses and casts of administration.
ITEM II
I will, devise and bequeath all of the property owned by me at the time
of my death to my husband, GARY L. HOLT, absolutely and in fee simple.
ITEM III
In the event, however, that my husband, GARY L. HOLT, should predecease
me, or that we should die as the result of a common disaster, then in either of
said events, I will, devise and bequeath all of the property owned by me at
the time of my death to my daughter. LISA H. FAULK, absolutely and in fee simple.
ITEM IY
I hereby designate my husband, GARY L. HOLT, as Executor of my Will, to
serve without bond. In the event, however, that my husband, GARY L. HOLT,
should predecease me or be unable to serve, I designate my daughter, LISA H.
FAULK, as Alternate Executrix of my Will, also to serve without bond. I do
give and grant unto my Executor or Alternate Executrix, whichever the case
may be, the power and authority to sell any property, both real and personal,
SEYMOUR
SEYMOUR . at either public or private sale without any Order of Court.
•^IOea.x.C. IN TESTIMONY WHEREOF, I do hereunto set my hand and seal, this 28th day
of November , 1989. (� ' / ,
So"'4s. f (SEAL'
DONNA S. HOLT
Page 2
The foregoing instrument was signed, sealed, published and declared by
DONNA S. HOLT, to be her Last Will and Testament, in our presence, and we at
her request and in her presence and In the presence of each other, have hereunto
subscribed our names as witnesses, this 28th day of November
/� 1989,
�1�.Ce en .� 9i. l3u�l.Cti residing at Delc;12-6din ( I? (--
WITNESS
WITNESS 99
\j'`j' , ` residing at ,d4„(. N.C.
WITNESS
STATE OF NORTH CAROLINA
COUNTY OF LEE
Before me, the undersigned authority, on this day personally appeared
DONNA S. HOLT, Testatrix, and Melissa D. Butler , and W. W. Seymour,Jr.,
witnesses respectively whose names are signed to the foregoing instrument, and
all of these persons being by me first duly sworn, DONNA S. HOLT, the Testatrix,
declared to me and to the witnesses in my presence that the instrument is her
Will and that she had willingly signed or directed another to sign for her, and
that she executed it as her free and voluntary act for the purposes therein ex-
pressed; and each of the witnesses state to me, in the presence and hearing of
the Testatrix, that they signed the Will as witnesses and that to the best of
their knowledge, the Testatrix was eighteen (18) years of age or older, of sound
mind, and under no constraint or undue Influence.
LD«Lwx a_,/ A-Jlst
Donna S. Halt, Testatrix
.�W I Witness
�Witne
ss
Subscribed, sworn and acknowledged before me by DONNA S. HOLT, the Testatrl ,
and sworn to before me by Melissa D. Butler , and W. W. Seymour, Jr.
:E vme uR witnesses, the28th day of November . 1989.
n
SEYMOUR /� 'l
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Notary Public
My Commission Expires: October 25, 1991 S. -�`
NOTARY
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09109111 Application#
Harnett County Central Permitting
Each sectioto n belowbe filled out PO Box 65 LAlington NC 27546
M whomeversectio pelfow tog work 910 893 7525 Fax 910 803 2793 www harnett orb/permits
Must be owner or licensed
contractor Address company Application for Residential Budding and Trades Permit
name 8 phone must match
Owners NameQh� 1/1�;P LF�c. It Date 7-/SS-17
Site Address r�,5 8'l P,a P V PCt.t P C t- /Q Gr Phone qty gs'z z lfi y
Directions to lob site from LAlmgton
Subdivision Lot
Description of Proposed Work S h 0 p 131 d 9 #of Bedrooms
Heated SF Unheated SF_ Finished Bonus Room' Crawl Space _Slab
General Contractor Information
Phi 111 FitiA. It
Building Contractors Company Name Telephone
. 5 8 1134 rhru4F C-, et,
Address Email Address
License#
Electrical Contractor Information
Description of Work IA) i 144 Shop Service Size 200 Amps T-Pole _Yes 4 Io
v.R. rig tiuc 9r9 - fryz. z i
Electrical Contractors Company Name Telephone
31o3 14a( 5:14e IJ✓ p4: lt,p � /g
p, ut tier At c ' Cas'-r
Address Email Ilddres6
License#
Mechanical/HVAC Contractor Information
Description of Work
Mechanical Contractor s Company Name Telephone
Address Email Address
License#
Plumbing Contractor Information
Description of Work #Baths 0
4.19 FYz- Z8//
Plumbing Contractors Company Name Telephone
a) tai �ax.r,P..ter�X x[ , ioi47
Address Vmail Adams
License#
Insulation Contractor Information
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 signing 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 aspercurrent fee schedule
Signature of er/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor t/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 dunng the permitted work from any person firm or corporation
carrying out the work �� "� ae nn'� /f
Company or Name P.g• Fa dei fit , c
Sign wRtlle $)I4lip 9a.,..tic Date 7- /F-17