BUILDING 00100x11 Application IS
Harnett County Central Permitting
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NOTE General Contractor must fill out and son ths second papa of the spoliation
I hereby certify that I have the autlonty t0 make necessary application that the appbcabon is correct
and that-the cansbucbon we conform to the regulations in Me Budding Bedell Plurnbdg and
Mechanical codes and the Harriet County Zoning Ordinance I state the IMonnaton on the above
contractors a correct as known to me and that by ammo kala-1 haw eMng d at whmntraofors
permeam to obtain tread writs and if any changes odour ncludmg listed contactors site pion
number of bedrooms building and bade plans Fmror-nidal Health pend changes or proposed use
Bungee I oertify d is my respomhbddy to notify the Harnett County Central Penner"DepmlmeM of
am and al changes
EXPIRED PERMIT FEES-a Months to 2 years permit reissue fee is$150 00 After 2 years reissue fee
is as per current fee sdedlde
5 - 1y - 18
Spnakiirtrrl onaadod (s)ofCorporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant baro to
V
General Contractor V Owner _Officer/Agent of the Contactor or Owner
Do hereby confirm under penalties of pe0urythat the person(s) frim(s)or corporaton(s)performing the work
set forth in the permit
Has tees(3)or more employee and has obtained workers cornpensabon insurance to cover them
Has one(1)or more subcontractors(s)and has obtained woman compensation Insurance to cover
two
Has one(1)or more subcoutadonne)who has their own potty of waters compensation insurance
coverer"themselves
Has no mon than two(2)employees and no subcontractors
Whde=dung on the project for which this pend a sought d e understood that the Central Permitting
Department issuing tce pent may retire celestes of coverage of workers compensation mawana prior
to issuance of the permit and at any We during the permitted work from any person firm or corporation
anying out the work
Company or fame
Sign wife 7l pontr-> Date `J- 14 -1?
LIEN AGENT INFORMATION
Effective April 1,2013
In accordance with North Carolina General Assembly Session Law 2012-158,
Inspection Departments are not allowed to issue any permit where the project cost
is $30,000 or more unless the application is for improvements to an existing
dwelling that the applicant uses as a residence OR the property owner has
designated a lien agent and provided the inspections office with the information
below:
Name of Lien Agent \n v e ors 1 -1-1(.., \nsurOnco en ryb(}nU
Mailing address of Agent V\ LI N C1tr 2. 1- 51 Slt lie so-)
9,0 .6''1 � vvJC- �
a�`
C\
O
Physical address of Agent 1 W 1/'1 a?-W 3 - SU t 12, 5cc
P-N g�, _NW- 971oc1
Telephone $gfi toga - 1314 Fax q13 - X189 . 5 31
Email .S Up?nr 1 lien Sne • Cor ,
The information will be attached to the permit record and a copy provided to the
applicant. The applicant is required to post a copy on the construction site.
Excerpt from North Carolina G.S. 160A-417:
"(Effective April 1,2013)No pemdt shall be issued pursuant to subdivision(1)of subsection(a)of
this section where the cost of the work is thirty thousand dollars($30,000)or more,other than for
improvements to an existing single-family residential dwelling unit as defined in G.S. 87-15.5(7)that
the applicant uses as a residence,unless the name,physical and mailing address,telephone number,
facsimile number,and electronic mail address of the lien agent designated by the owner pursuant to
G.S.44A-11.1(a)is conspicuously set forth in the permit or in an attachment thereto.The building
permit may contain the lien agent's electronic mail address.The lien agent information for each
permit issued pursuant to this subsection shall be maintained by the inspection department in the
same manner and in the same location in which it maintains its record of building permits issued"
www.liensnc,com
Appointment of Lien Agent:Details-LiensNC Lien Service https://apps.liensnc.com/scr/appointment/details.html?entryNumber—...
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 05/10/2018
Entry #: 850224 Initially filed by:
southerntouchhom•Sllc
Designated Lien Agent Project Property Print & Post
investors Title Insurance Company Sheriff Johnson Road El On
Angier,NC 27501
ondoe:www.hrmnceoma.....u...., Harnett County
AEAm 19 W.Hargen St Shce 507/Raleigh.NC Or
PWI Contractors:
Phone:888590.7384 Property Type Please post this notice on the Job Site.
rn:915459.5731 Suppliers and Subcontractors:
Scan this image with your smart phone to
1-2 Family Dwellingew this filing.You can then file a Notice
toLien Agent for this project
Owner Information Date of First Furnishing
Bryant Lockamy O5rz52018
Po Box 2135
Angier, NC 27501
United States
Email:southemmucliomesllc(oJglnailcom
Phone:919-639-4672
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