BUILDING, PERMIT & RECEIPT 09109111 Application# / ,,CA
Harnett County Central Permitting IS — Sti�ic U 3 c✓
PO Box 85 Lllhngton NC 27548
Each section below to be filled out 910 893 7525 Fax 910 B93 2703 www hame9 mg/permits
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match 1 l
Owners NemeI 1�c k'rTT x \r A
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Site AddressL,IS1 Q3C 91 l.JC54- LiAln9E i N1C°nealo-RRm-1313
Directions to job site from Lillington
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Into ntractor Information
Insulation Contractors Company Name 8 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 starring below I have obtained all subcontractors
permission to obtain these permits and if Iny 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 an• changes
PJ as r 'ERMIT
' EShe •B •nip permit re-issue tea is 8150 00 After 2 years re-issue fee
as �• •• rrent fee -chedule
sl � i I .
Signature •-swner/C.- •r O'icer(s) rporation Date
Affidavit for Worker's Compensate ‘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 perms
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 war
Company or Name OP.tn rl'( H r" ° f/
Sign waitle�x -I 1....„)6vA„..> Date
Effective Date: 05/01/2018 _
NORTH CAROLINA MODULAR BUILDING
SET-UP CONTRACTOR LICENSE BOND
# 3398008
WE, EJ WOMACK ENTERPRISES,INC DBA:RAVEN ROCK MOBILE HOME MOVERS as principal,
located at 3335 NC HWY 87 SANFORD,NC 27546
and SureTec Insurance Company
(surety)of 1330 Post Oak Blvd,Ste 1100 Houston,TX 77058
(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 6781 NC 27 WEST
City LILLINGTON _,- , 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
act or 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
1st day of May _ 2018 ,the name and corporate seal of each corporate party
being hereto affixed and these presents duly signed be its undersigned representative, pursuant to authority of its
governing body.
All
Signature of Principal
RPM
Ir T
S re ac Ins .- •ompa Title
Surety by p -
(signature)
David Gonsalves
(printed name)
Tile Attorney-in-fist_-
Addr s 1330 Post Oak Blvd,Ste 1100 Houston,TX 77056
�JaReF111�
;I1)1
Davi Gunse�NQJ/es
N.C.Resident Agent
3•tea
14045 Ballantyne Corp P1,Ste 525,Charlotte,NC 28277
Address
Power of Attomey Attached
•
•
POA#:3398008
SureTec Insurance Company
LIMITED POWER OF ATTORNEY
Know Ail 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 Attomey-in-fact,with full power and authority hereby conferred in its name,place and stead,to execute,aclmowledge
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:u WOMACK ENTERPMSES,INC au:RAVEN ROCK MOBILE NOME 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 at 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.
�sJtuaioFC SURETEC CO '/ NY
is, .4
°s By: _/_dt
ur John Itno �.,Presid t
State ofHar Texas as:
i� 1 .�v
County Harris
On this 6th day of April,A.D.2017 before me personally came John Knox,Jr.,to me known,who,being by me I ly sworn,did depose and say,that he
resides in Houston, Texas, that he is President of SURETEC INSURANCE COMPANY, the company des- red 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.
. No000ubYN Ga a of Texas I/ /i (� /�'
A°l,Ap .JNotary ACO%JELiN GREolLExas
AF Ii J IVVVI IYYYi If
oto^:r ° Comm.Expires 05-18-2021
';°;,;:� Notary ID 128803029 Ja uelya 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 fill force and effect;and furthermore,the resolutions of the Board of Directors,set
out in the Power of Attorney are in full force and effect.
Given under my hand and the seal of said Company at Houston,Texas this JSt days Ma 018 A.D.
M.Brent eaty,Assistant Secretary
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 8:00 am and 6:00 pm CST.
DO NOT REMOVE!
Details: Appointment of Lien Agent
Filed on: 05/03/2079
Entry #: 845889 Initially filed by: countryfalrhomes
Designated Lien Agent Project Property Print & Post
Fidelity National Ti0e Company,LLC' 67Nl ne hwy 27 west -
IillingtanNC27546hp.
Online: Com . . Harnett County N ,sh9, w"1
3.'a
Add W.Hargett St S ./N9eiyL.Nc
2.7601
Contractors:
Phone:88S.690.71/14 Property Type Please post his notice on the lob Site.
Pax:913-4 9-5211
Suppliers and
tractors:
Email: pm lumencum Scanthis image with your smart
le
1-2 Paidily Dwelling thisview mina,You can then rte aNotice
to Lien Agent for this project.
Owner Information
brittny lee
1418 monis chapel rd
sanford. NC 27330
United States
Gnail:embio20 t(rygmail com
Phone:919-498-4806
View Comments(0)
Technical Support Hotline:(NM 690-7353
HARNETT COUNTY CENTRAL PERMITTING
P.O. BOX 65
LILLINGTON, NC 27546
For Inspections Call : (910) 893-7525 Fax: (910) 893-2793
Application Number 18-50043641 Date 5/04/18
Property Address 6781 NC 27 W
PARCEL NUMBER 13-0528- - -0072- - -
Application type description CP MODULAR HOME
Subdivision Name
Property Zoning PENDING
Owner Contractor
E J WOMACK ENTERPRISES INC RAVEN ROCK MOBILE HOME MOVER
3335 NC 87 S 3335 NC 87 HWY.
SANFORD NC 27332 SANFORD NC 27332
(919) 775-3600
Applicant
LEE BRITTANY
1418 MORRIS CHAPEL RD
LILLINGTON NC 27546
(910) 890-7313
--- Structure Information 000 000 32X64 3BDR 2BTH OFF FRAME
Flood Zone FLOOD ZONE X
Other struct info # BATHS 2
# BEDROOMS 3 . 00
SEPTIC - EXISTING? NEW SEPTIC
WATER SUPPLY COUNTY
Permit LAND USE PERMIT
Additional desc .
Phone Access Code 1241207
Issue Date . . . 5/04/18 Valuation . . . . 0
Expiration Date . 10/31/18
Permit MODULAR PERMIT
Additional desc .
Phone Access Code 1241041
Issue Date . . . 5/04/18 Valuation . . . . 0
Expiration Date . 5/04/19
Special Notes and Comments
T/S: 03/26/2018 02 : 39 PM LLUCAS ----
NC 27 WEST
TRAVEL HWY 27 WEST TOWARDS WESTERN
HARNETT HIGH SCHOOL - GO ABOUT 5 MILES
PROPERTY IS ON THE LEFT AFTER TIM
CURRIN / HIGHWAY 27 W INTERSECTION
HARNETT COUNTY CENTRAL PERMITTING
P.O. BOX 65
LILLINGTON, NC 27546
For Inspections Call: (910) 893-7525 Fax: (910) 893-2793
Page 2
Application Number 18-50043641 Date 5/04/18
Property Address 6781 NC 27 W
PARCEL NUMBER . 13-0528- - -0072- - -
Application description . . CP MODULAR HOME
Subdivision Name
Property Zoning PENDING
Required Inspections
Phone Insp
Seq Insp# Code Description Initials Date
Permit type . . . . MODULAR PERMIT
10 101 B101 R*BLDG FOOTING / TEMP SVC POLE / /
20 103 B103 R*BLDG FOUND & TEMP SVC POLE / /
20 814 A814 ADDRESS CONFIRMATION / /
30-40 119 B119 R*MOD MARRIAGE WALL / /
40-50 425 R425 FOUR TRADE ROUGH IN / /
40-50 125 R125 ONE TRADE ROUGH IN
40-50 325 R325 THREE TRADE ROUGH IN
40-50 225 R225 TWO TRADE ROUGH IN
50-60 131 R131 ONE TRADE FINAL / /
50-60 429 R429 FOUR TRADE FINAL / /
50-60 329 R329 THREE TRADE FINAL / /
50-60 229 R229 TWO TRADE FINAL / /
999 H824 ENVIR. OPERATIONS PERMIT / /
HARNc T COUNTY CASE RECEIPTS
$$e CUSTOMER RECEIPT ***
Oper: TBROCK Tyne: CP Drawer: 1
Date: 5/04/16 52 Receipt no: 342478
Year Number Amount
2018 5004i64i
6781 NC 27 W
' LILLIHGTON_, NC 27546
Al BP - PERMIT FEF
MOD $425.00
E J WOMACK
Tender detail
CK CHICK PAYMEN 53706 $425.00
Total tendered $425.00
Total payment 8425.00
Trans date: 5/04/18 Time: 13:32:47
** THANK YOU FOR YOUR PAYMENT **