DOCUMENTS Initial Application Date--''Cl I lI Application#I O S01343-Ng
mit
COUNTY OF HARNETT RESIDENTIAL LAND USE APPLICATION
Central Permitting 108 E.Front Street Lillington,NC 27546 Phone:(910)893-]525 ext:2 Fax:(910)893-2793 www.harnettorg/permits
"A RECORDED SURVEY MAP,RECORDED. DEED(OR OFFER TO PURCHASE)&SITE PLAN ARE REQUIRED WH�ENNSSUBMITTING A LAND USE
APPLICATION"
LANDOWWNER::r�I)6I-nntri d ✓ u I n 7DOSt" y._ Mailing Address: LL23 Pa lers:3n I^U - /�
City: ?/f ` 3-CL'�-la't'h State.kJ( Zip:¢LTi ontact No:q 1 51 I-3311 Email: L fl n p I?o3ft Ciao; 1.(0-11
APPLICANT': S(Mh-C- A5 O..bJ 1C—Mailing Address:
City: State: Zip: Contact No: Email:
'Please fill out applicant Information if different than lanaowneerrfT� /j II
CONTACT NAME APPLYING IN OFFICE: \/ 11 1n�` i (� Phone ft q)o-S1Y 3311
PROPERTY LOCATION:
yqSubdivision: , ]t'Lt\4fllj 1l \ 4- Lot ft: -� Lot91011
Size: vI,•.0Q�
State Road# 0.I0 1 State Road� Name:( '(�-f te1� n Pei . fir((Maap-BBook&Page:9V I I / CASS
Parcel: I 3 61o0t b�"'f y PIN: (�U/�CCI�/�� r54— a'JTrt•000
zoning fk A'36 Flood Zone:L V Watershed: x. Deed Book&Page&K SID ( LI a.I Power Company':
*New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
PROPOSED USE:
Monolithic
❑
SED:(Size x )k Bedrooms:_#Baths: 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)
❑ Mod:(Sae 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
❑ Manufactured Home:_SW_DW TW(Size x )/4 Bedrooms:_Garage: (site built? )Deck: (site built? )
❑ Duplex:(Size x )No.Buildings: No.Bedrooms Per Unit:
❑ Home Occupation:#Rooms: +/ ��ss c� Use'. L/Hours of Operation:er� J 1. #Employees:_
l AddNon/Accessory/Other:(Size lb xo�1 )Use: -bi I 3l reel porch )decL-Cbsets in addition?(_)yes ( 'tno
Water Supply: V 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 (=7 no
Does the property contain any easements whether underground or overhead(_)yes O ldrrro
Structures(existing or proposed).Single family dwellings: I Manufactured Homes: Other(specify):
Required Residential Property Line Setbacks: Comments:
Front Minimum Actual
Rear
Closest Side G"t
Sidestreet/corner lot
Nearest Building
on same lot
Residential Land Use Application Page 1 of 2 03/11
APPLICATION CONTINUES ON BACK
•
SPECIFIC DIRECTIONS TO THE PROPERTYFROM LILLINOT II bel �O coU S ,I j N , �U rn �k+
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iteron U(YJa C7Xnn Y1
If permits are granted I agree to co 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 state ent acre accu and co ect to the best of my knowledge. Permit subject to revocation if false information is provided.
Signature of Owner or Owner's Agent s Datei
"'It is the ownerlapplicants responsibility t' provide the county with any applicable information about the subject property,including but not limited
to:boundary information,house location,undergrounra or overhead easements,etc.The county or its employees ate 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: I /Qfif1ikdV1S& APPLICATION di
*This application to be Riled 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 plain without expiration)
910-893-7525 option I CONFIRMATION#
Environmental Health New Septic SystemCode 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 Existino 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 indicat- esired system type(s): can be ranked in order of preference,must choose one.
( 1 Accepted 1-1 InnovativeConventional 1-1 Any
1 1 Alternative ( I Other
The.pplicant shall notify the local heal • department upon s bmittal of this application if any of the following apply to the property in
qua tion. If the answer is"yes",appli.. t MUST ATTACH 4.UPPORTING DOCUMENTAT a :
1_ YES 1 ) NO Does the ite contain any Jurisdicti'nal Wetlands? )
1 YES 1-1 NO Do yo plan to have an irri)ati on s Ltem now or in the future?
1_ YES 1I NO Doe, or will the building contain an- drains?Please explal..
I 'YES II NO Ari there any existing wells,springs,waterlines or Wast• Ater Systems on this pr..erty?
( ES 1—I NO is .ny wastewater going to be genera cd on the site oth; than domestic sewage?
1-1 ES 1—I NO the site subject to approval by any her Public Ago cy?
1—I ES 1 ) NO Are there any Easements or Right of .ys on this p•.perry?
1 }Y'.5 I1 NO Does the site contain any existing water cable,ph. e or underground electric lines?
If yes please call No Cuts at 800-632-49,9 to lo :to the lines. This is a free service.
I Have lien I This Ap cation And Certify That The Information Provid.I 9n Is True,Complete And Correct. Authori ounty 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 Acce b e 5 TThay Comp e Site Evaluation Can Be Performed.
19 1
PROPERTY OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) ATE
10/10
09/09/11 Application#
Harnett County Central Permitting
PO Box 65 Lillinglon NC 27546
Each sedan below to be filled out 910 893 7525 Fax 910 893 2793 www homed mg/permits
by whmnmer pertaining work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match / /t L� // /7
Owners Name n/innl11 and rr]]}. Mil W5.1 Date T'(1"l QJ
Sae Address CO a... Taiie Son ria . .�hyril u vitt A1C Phone gfd- 514-'13/f
Directions to lob site from Llllington 4141 d. -17:1 KecA Ta f- cn 'P 4 . --Qnd. hou5f_-
nn tef3. IU14+1 irirvi Lh, hack_
Subdivision 11 I Ol- Lot
Description of Proposed Work 60 VW in Ewe- ('1 icier K #of Bedrooms cn
Heated SF O Unheated SF Lig l3 Finished Bonus Room't Crawl Space =Slab
General Contractor Information
Building Contractors Company Name Telephone
Address Email Address
`^
License#
Electrical Contractor Information
Description of Work Service Size _Amps T-Pole _Yes_No
Electrical Contractors Company Name Telephone
Address Email Address
DDlAir
License#
Mechanical/HVAC Contractor Information
Description of Work —\
Mechanical Contractor s C any Name Telephone
dress
Email
License#
Plumbing Contractor Information
Descnption of Work Baths
Pluiff1i\bang Contractor s pany Name Telephone
Add rdss_/ mail Address
License#
I . . a. • i • i cm. u • ui •n
Insulation Contract ompany 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 pv mama below I have obtained all subcontractors
permission to obtain these permits and 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$150 00 After 2 years re-issue fee
is as current ee schedule
u I 0.09— 14I611 (9-D18
Signature of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation NC G S 87-14
The undersigned applicant being the
General Contractor Ve Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of penury 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
(k IA
Company or Name A-A,A M
Sign w/Title 01 ono_2 I Date I lei I ii3
HARNETT COUNTY CA5B RECEIPTS
*** CUSTOMER RECEIPT ***
aper: 7BROCK Type: CP Drawer: 1
Date: 4/89/16 52 Receipt no: 314493
Year Number Amount
2818 50043744
623 PATTERSON RD
BROADWAY, NC 27505
84 BP - ENV HEALTH FEES
f180.08
EXT
DANHYT BOST
Fender detail
CK CHECK PAYMEN 5036 $108.80
Total tendered $100.00
Total payment
Trans date: 4/89/18 Time: 9:13:35
** THANK YOU FOR YOUR PAYMENT **