DOCUMENTS Initial Application Date: 75 -1 / / Application# ' 5V0a 3
CU#
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.org/permits
**A RECORDED SURVEY MAP,RECORDED DEED(OR OFFER TO PURCHASE)&SITE PLAN ARE REQUIRED�WHEN�SUBBMIITTTINGCA LAND USE APPLICATION"
LANDOWNER: G 6O R GC J 0 14/./ .SA C 08 S Mailing Address: Z!5 Bd�-Q'f"`1 I E S+( /� l
City: SP(�.INS6 LAKE State:NC) Zip:24Y1 Contact No: It 476 0600 Email: 9eOJacOIJS365/4811
APPLICANT*: 5 kM E Mailing Address:
City: State: Zip: Contact No: Email:
*Please fill out applicant information if different than landowner
CONTACT NAME APPLYING IN OFFICE: /- Phone# j Q
PROPERTY LOCATION:Subdivision: � (\ �ic_ Lot#: S� Lot Size: •/ 1`. , 1
c.
State Road# State Road Name: �.. ery c.r-C I S+ Map
Book&Page: IS 1 I I
Parcel: t>�y1 _ OS,S Y(> I L� PIN: b i S ^ 149 I - t $ • v 0 V 111
Zonin �t�Flood Zone: X Watershed: Deed Book&Page3a00 /L037 Power Company":
*New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
PRO OSED U35:
1.7 Monolithic
l� SFD:(SiziSV1 x 41)#Bedrooms: #Baths:1 Basement(w/wo 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)
U Mod:(Size x )#Bedrooms_#Baths_Basement(w/wo bath)_Garage:_Site Built Deck:_ On Frame_Off Frame_
(Is the second floor finished?(_)yes (_)no Any other site built additions?(_)yes (_)no
U Manufactured Home:_SW_DW_TW(Size x )#Bedrooms:_Garage: (site built?_)Deck: (site built?_)
❑ Duplex:(Size x )No.Buildings: No.Bedrooms Per Unit:
❑ Home Occupation:#Rooms: Use: Hours of Operation: #Employees:
❑ Addition/Accessory/Other:(Size x )Use: Closets in addition?(_)yes (_)no
Water Supply: A./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: anufactured Homes: Other(specify):
r
Required Residential Property Line Setbacks: Comments:
Front Minimum 3S Actual ! t
Rear _
Closest Side I
Sidestreet/corner lot
Nearest Building
on same lot
Residential Land Use Application Page 1 of 2 03/11
APPLICATION CONTINUES ON BACK
4-ur+N g-4- Ws'
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON: 50 u4- 2-10 4 0 Vtl')t It S
-Turn, IL-t on, Arc,k bC 5,4e +0 ZD RIM' mock as YIG
Dn corArr 0,4 L c Z5 5fr DV' 53 5Li 55
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 statements are accurate and correct to the best of my knowledge. Permit subject to revocation if false information is provided.
7.064.ems. 8- 94`?
.•-i,
Signature of 0 er or Owner's Agent Date
***It is the owner/applicants responsibility to provide the county with any 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
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NAME: asE0l2-6>G TA,'-SIS 5 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 1 CONFIRMATION#
Environmental Health New Septic SvstemCode 800
• All property irons must be made visible. Place "pink property 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 1 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 LIDS 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(s): can be ranked in order of preference,must choose one.
{_} Accepted {_} Innovative {{} Conventional {_} Any
{_} Alternative {_} 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 ( 4 } NO Does the site contain any Jurisdictional Wetlands?
{_}YES { J} NO Do you plan to have an irrigatio system now or in the future?
{ }YES {J } NO Does or will the building contain any drains?Please explain.
{_}YES (4)NO Are there any existing wells,springs,waterlines or Wastewater Systems on this property?
{_}YES {)} NO Is any wastewater going to be generated on the site other than domestic sewage?
(_}YES {J } NO Is the site subject to approval by any other Public Agency?
{_}YES (N/} NO Are there any Easements or Right of Ways on this property?
{_}YES (4} 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 That 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 Accessible So That A Complete S Evaluati n Can Be Performed.
PROPERTY OWNERS OR OWNERS LXGAL REPRESENTATIVE SIGNATURE(REQUIRED) DATE
10/10
09109111 Application#
Harnett County Central Permitting I
PO Box 65 Lainpton NC 27548
Each sexton Sow to be Med out 910 693 7525 Fax 910 893 2793 www name one/permits
by who never performing work
Must be owner or licensed
contactor Address oxmpany Application for Residential Buildino and Trades Permit
name 6 phone must match --� /� ��
Owners Name f i�Ai CC `1')•N-+� l • kirS Date ____ L_/
Site Address R t-Q/1Q.�'hJl Phone r l L�-i v i. 6 5
Directions to lob site from Lillington
SubdivisionlLot
DeacDescriptionn of Pryposed Work ✓�
-�1 11`)\ #of Bedrooms
Healed SF / Unheated SF Finished Bonus Room?_Crawl Space _Slab _
General Contractor Information
Building Contractor s Company Name Telephone
Address Email Address
N k
License#
glectrical Contractor Information
Description of Work Service Size _Amps T-Pole _Yes_No
Electrical Contractor a Company Name Telephone
Address Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work
Mechanical Contractor s Company Name Telephone
Address Email Address
O\ k_Ar /-
License#
plumbma Contractor Information
Description of Work #Baths
Plumbing Contractor s Company Name Telephone
Address Email Address
(M)\ \A
License#
insulation Contractor Information
(Th A Jl\ Telephone
Insulation Contractor Company Name&Address P
'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 alumna below I have obtained all subcontractors
permission to obtain these owlets end if any 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 5150 00 After 2 years re-issue fee
is as per current fee schedule
tr.:-6i -1-
Signature of Owner/Con6act /Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor V Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) firm(s)or corporaton(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 aubcontractors(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 t mselves
as 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 dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name
Sign w/Title ;}cc.r icCt- . Date ( R/ / /
Sept 28th 2017
To whom it may concern:
I will pay as Igo throughout this project and will have it paid in full by completion. There will be
no financing on this log cabin.
i
George Jacobs
State of North Carolina
Pa-
County of Cumberland
I, PwQA �c,yyAor- ,a Notary. Public
for said County and S'tlat .Ao herby certify that
lb Qor52. 4-, J4C.c� S
personal) appeared before me this day and
acknowledged the due execution of the foregoing
instrument.
Witness illy had an official seal,this
the ay of >n e' _ 2Pt1.
\\\\\\IluPau/i2%%%.
.- .4 '4
eC Nord
:a gellc
%;;;<,'a Co N`\\\` signature of notary Public
My commission expires ec-t ser , h Lo .S
month day year
STATE OF NORTH CAROLINA OWNER EXEMPTION AFFIDAVIT
COUNTY OF t,i .� LT-
SS PURSUANT TO G.S.87-14 (a)(1)
Qyl\1iYC Inspection Department
Parcel Identification Number and address where the building Is to be constructed:PIN O IS-L aI .,LCD%• J'-
Address 13''Q`
Type of construction:a Residential 0 Commercial DIndustrial ❑Other
Intended use after completion(e.g.Personal residence): -/'
Building permit number associated with this application: � ,.i.
�._ Lr.:� -1 ; . 11i .Ti , _ AIC 7‘ ( C.<r!
(Print Full Name) (Phone Number)
hereby claim exemption from licensure under G.S. 87-1(b)(2)by Initialing the relevant provision in paragraph I
and Initialing paragraphs 2-5 below attesting to the following:
I. I certify I am the owner of the property set forth above on which a building is to be constructed or
altered and for which application for a building permit is hereby made;
OR
I am legally authorized to act on behalf of the firm or corporation that is constructing or altering this
building on the property owned by the firm or corporation as set forth above:
(Name of Firm or Corporation)
2. /Sir I will personally superintend and manage all aspects of the construction or alteration of the building
and that duty will not be delegated to any person not duly licensed under the terms of Article 1.Chapter 87
of the.Ganeral Statues of North Carolina.
vIl
3. %fY I will be on site regularly during construction and I will be personally present for all inspections required
by the North Carolina State Building Code, unless the plans for the construction or alteration of the building were
drawn and sealed by an architect licensed pursuant to Chapter 83A of the General Statutes of North Carolina.
4. ) \ I understand that by executing this licensing exemption AFFIDAVIT pursuant to G.S.87-1(b)(2),I am
required by law to occupy the building for which the licensing exemption is granted for twelve months after
pleron,during which time it may not be offered for rent,lease or sale.
5. 4 ' V I understand a copy of this AFFIDAVIT will be transmitted to the North Carolina Licensing Board for
General Contractors for verification 1 am validly entitled to claim an exemption under G.S.87-1(b)(2)for the
budding construction or alteration specified herein.I further understand if the North Carolina Licensing Board
for General Contractors determines I am not entitled to claim this exemption the building permit issued for the
construction or alteration specified herein shall be revoked pursuant to G.S 153A-362 or G.S. 180A-422.
aS- i • 1. 7 / m /
(Meng(Signature of(Meng (Date)
Swom or affirmed and subscribed before me this the -a oil,
of L a 20 17
d
I.
x�xltQcaul r Tdy,O
/ (Signature of Notary Public) ` �T
` (Notartamp or Sa1gfe,�
t 1,1/4.-- _n _s
'`
(Printed Ne of Notary Public) !, ¢ to/6/votq �G1 '"blIc
e.
(NOTE:It is a class F felony to willfully commit pedury in any affidavit taken pursuanE G.S. 14-20*$
l4/4ald CO•t.0.
HARNETT COUNTY CENTRAL PERMITTING
P.O. BOX 65
LILLINGTON, NC 27546
For Inspections Call : (910) 893-7525 Fax: (910) 893-2793
Bldg Insp scheduled before 2pm available next business day.
Application Number 17-50042031 Date 9/27/17
Intersection
Property Address BERNARD ST
PARCEL NUMBER 01-0515- - -0166- - -
Application type description CP NEW RESIDENTIAL (SFD)
Subdivision Name ANDERSON CREEK HOMES
Property Zoning PENDING
Owner Contractor
JACOBS GEORGE JOHN OWNER
25 BERNARD STREET
SPRING LAKE NC 28390
Applicant
JACOBS GEORGE JOHN
25 BERNARD ST
SPRING LAKE, NC 28390
SPRING LAKE NC 28390
(910) 476-0688
--- Structure Information 000 000 54X41 2BDR 1BA CRAWL W/ GARAGE
Flood Zone FLOOD ZONE X
Other struct info # BEDROOMS 2000000 . 00
PROPOSED USE SFD
SEPTIC - EXISTING? NEW TANK
WATER SUPPLY COUNTY
Permit BLDG, MECH, ELEC, PLB, INSU PERMIT
Additional desc .
Phone Access Code 1204577
Issue Date . . . 9/27/17 Valuation . . . . 0
Expiration Date . 9/27/18
Special Notes and Comments
T/S : 08/09/2017 03 :40 PM JBROCK - ---
210 R ON OVERHILLS RD R ON ARCHIE ST
2ND R WHICH IS BENARD ON CORNER ON L 25
BERNARD ST
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
PERMIT INCLUDES BLDG, ELEC,MECH, PLUMB
INSULATION AND LAND USE.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Work must conform and comply with the
STATE BUILDING CODE and all other State
and local laws , ordinances & regulations
HARNETT COUNTY CENTRAL PERMITTING
P.O. BOX 65
LILLINGTON, NC 27546
For Inspections Call : (910) 893-7525 Fax: (910) 893-2793
Bldg Insp scheduled before 2pm available next business day.
Page 2
Application Number 17-50042031 Date 9/27/17
Property Address BERNARD ST
PARCEL NUMBER 01-0515- - -0166- - -
Application description . . CP NEW RESIDENTIAL (SFD)
Subdivision Name ANDERSON CREEK HOMES
Property Zoning PENDING
Permit BLDG, MECH, ELEC, PLB, INSU PERMIT
Additional desc .
Phone Access Code 1204577
Required Inspections
Phone Insp
Seq Insp# Code Description Initials Date
10-30 814 A814 ADDRESS CONFIRMATION / /
10 101 B101 R*BLDG FOOTING / TEMP SVC POLE / /
20 103 8103 R*BLDG FOUND & TEMP SVC POLE / /
30-999 105 B105 R*OPEN FLOOR / /
40-50 129 1129 R*INSULATION INSPECTION
40-60 425 R425 FOUR TRADE ROUGH IN / /
40-60 125 R125 ONE TRADE ROUGH IN / /
40-60 325 R325 THREE TRADE ROUGH IN / /
40-60 225 R225 TWO TRADE ROUGH IN / /
50-60 429 R429 FOUR TRADE FINAL / /
50-60 131 R131 ONE TRADE FINAL / /
50-60 329 R329 THREE TRADE FINAL / /
50-60 229 R229 TWO TRADE FINAL / /
50-60 209 E209 R*ELEC TEMP POWER CERT / /
999 H824 ENVIR. OPERATIONS PERMIT / /
999 H828 ENVIRO. WELL PERMIT / /