BUILDING / LIEN wedBRtono-f„e pp
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00/09/11 Application fl
Harnett County Central Permitting SOD (431 e{�j R
Each eepbon below to be 011aJ outPC sox 65 L6linelon NC 27545
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contractor Aadresa company Application for Residential Budding and Trades Parmtt
nemo a phone must mach �
Owners Name _ O 1 44-ornes Li-a• DaleL _
SiteAddress'4Z ercck Q-rl 13L-.nnl-tL?-f Phoneg10481048ta4
Directions to lob site from Lillinglon cg los -i-f, i Tri- -P4'i rose S •1-0 ('IC j„e -
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Subdivision /1Lot X
Description of Proposed Work SIVlfllt•Pitm t4 DM-111118 it of Bedrooms -
Heated SF 41S I Unhealed SF V Finished onus Room? _J_Crawl Space _Slab
General Contractor Information
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Building Contractors Company Name F0.4 f1C. Telephone
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Address ETnail Address
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.S.FD �t peon el Contractor Informatiory,
D?scrlolion of War «4VCo-�_Service Size '/.DO Amps T-Pole/ Yes No
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Sled?al Conlo .Inr a f:mmnanv Telephone
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Description of Work '[VQC -FOY SF0
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Mechanical Contractors Company Name Telephone
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Address Email Address
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License#
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( 7p�JumbinnntCContractor Information
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Insulation Contractor Information
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Insulation Co ora Company Name&Address Telephone
'NOM General Contractor must fill out and sign the socond page of this application
I hereby certify that I have the authority to make necessary application that the application is correct
and Ilial-the construction will conform to the regulations in the Building Electrical Plumbing and
Mechanical codes and the Harnett County Zoning Ordinance I elate the information on the above
contractors as correct as known to me and That pv sinning below I have obtained all aubooniraotore
permission to obtain these permits end if g0X changes occur including listed contractors site plan
number of bedrooms building end trade plana 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-e Months to 2 years permit reissue fee is$160 00 After 2 years re-issue fee
is as par current fee schedule
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SlgnaWrOwnero aT /Conlfp lora /OOffiner(s)of Corporation Date
Affidavit for Worker's Compensation N C 0 S 87.14
The undersigned applicant being the
kGeneral 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
XHas three(3)or more employees and has obtained workers compensation insurance to cover them
Has one(1)or more subcontractors(s)end 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 il Is understood that the Central Permtling
Department issuing the permit may require certificates of coverage of worker s compensation insurance prior
to Issuance of the permit and at any lane during the permitted work from any person firm or corporation
carrying out the work 1 ��
Company or Name PnSi4-e ‘4n-c*'c I1 C.� 11
Sign wRNe Dm' Y
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Appointment of Lien Agent: Details- LiensNC Lien Service Page 1 of 1
DO NOT REMOVE!
Details: Appointment of Lien Agent
Filed on: 041241201e
Entry M: 839391 Initially flied by: !remittal
Designated Lien Agent Project Property Print & Post
First American Title Insurance Company LOT 08
48 Brock Rd { (-'f
Bunnlevel,NC 18323 '
AdJror NW HanceSi,Sm¢WI I Rabmgh NC Emmet Count) '5-'3°
21601
Con
Mane:AA&49,73e4 Please post this notice on he lob Site.
F.,"9134593331 Property Type
Suppliers and Subcontractors:
Lmril:2Ji SILrnw mm. a...... Scan ibis image with your sman phone
view this filing You®ntban file a Notice
1-2 Family Dwelling to Lien Agent for this pmlat.
Owner information
Date of First Furnishing
Onsite Homes LLC
2919 Breezewood Ave
Ste 300 /23/2018
Fayetteville. NC 18303
United States
Emailtravinalove@onsitehomemc corn
Phone.910-745-0001
View Comments(a)
Technical Support Hotline:(888)690-7384
https://apps.liensnc.com/scr/appointment/details.html?entryNumber=839391&printable=Y 4/24/2018