DOCUMENTS Initial Application Date: tel.IS l0 Application# ` LA .,-]l-JL `` l U
DRB# CU#
COUNTY OF HARNETT LAND USE APPLICATION
Cannel Hamming (Phy&tal)100 E Front Street,011iylon,NC 27546 {Mailing)PO Box 85 Lillington NC 27546 Phone:(910)893-7525 opt II2 Fax:(910)893-2793 vwxdarnellorg/gnrvls
LANDOWNER: Harnett County School Mailing Address: P.O.Box 1029
City: Lillington State: NC Zip: 27546 Contact# 910-985-1003 Email: rgregory1c hamett.k12.nc.us
APPLICANP: Harnett County School Mailing Address: P.O Box 1029
City: Lillington State: NC Zip: 27546 Contact# 910-985-1003 Email: rgregory1@hamett.k12.nc.us
'Please till out applicant information it diff Brent than landowner
CONTACT NAME APPLYING IN OFFICE: Rodney Gregory Phone it 910-985-1003 /� I
1
PROPERTY LOCATION:Subdivision: Western Harnett High School Lot#'. Lot Size:r1 �. 0
State Road
dF��# (State Road Name: 10637 NC HWY.27 West,Lillington�y - NC /� MapapBook&Page: r
Parcel: 11�Ab-•z�.t T" tri —16U� PIN: bS57 (-��1SI - d 101 .60..\
Zonis .f Flood Zone: lc Watershed: Deed Book&Page�'%c ft1— 5 Power Company
'New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON:
PROPOSED USE:
❑ Multi-Family Dwelling No.Units: No.Bedrooms/Unit:
❑ Business Sq.Ft.Retail Space: Type: #Employees: Hours of Operation:
❑ Daycare #Preschoolers: #Afterschoolers: #Employees: Hours of Operation:
❑ Industry Sq.Ft: Type: #Employees: Hours of Operation:
❑ Church Seating Capacity: #Bathrooms: Kitchen:
❑ Accessory/Addition/Other(Size 24 x 36 )Use: Mobile Classroom with no plumbing
Water Supply: 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
Comments:
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.
/ G -ice -A9S natureOwnm Owner's Agent Date
"This application expires 6 months from the Initial date if permits have not been issued""
A RECORDED SURVEY MAP,RECORDED DEED(OR OFFER TO PURCHASE)AND PLAT ARE REQUIRED WHEN APPLYING FOR LAND USE APPLICATION
'Each section below must be filled out by Application#
whoever is performing the work. Must be Harnett County Central Permitting
owner or licensed contractor. Address, PO Box 65 Lillington,NC 27546
company name 8 phone must math 910-893-7525 Fax 910-893-2793 wwwharnett.org/permits
information on state license. COMMERCIAL
Application for Building and Trades Permit
Owner's Name: Harnett County School Date:
Site Address: 10637 NC Hwy.27 West Phone: 910-893-4808
Directions to job site from Lillington: Take 27 west out of Lillington school will be on Left
Subdivision: Lot:
Description of Proposed Work: Building a mobile classroom 24'x 36'
Heated SF 864 Unheated SF
General Contractor Information: Building Cost$ 10000.00
Harnett County school 910-893-4808
Building Contractor's Company Name Telephone
1500 South main SLLillington,NC 27546 rgregory1@hamett.k12.nc.us
Atltlr Email Address
Signature o wner/Cont ctor/Officer(s)of Corporation License#
Electrical Contractor Information: Electrical Cost$ 500.00
Description of Work Wiring service panel Service Size: 100 Amps #T-Poles
Harnett County School
Electrical Contractor's Company Name Telephone
1500 South main St.Lillington,NC 27546
Address )) Email Address
Signature of wner/Co c7o2ifficer(s)of Corporation License#
Mechanical Contractor Information: Mechanical Cost$
Description of Work #Units
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature of Owner/Contractor/Officer(s)of Corporation License#
Plumbing Contractor Information: Plumbing Cost$
Description of Work - #Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
Signature of Owner/Contractor/Officer(s)of Corporation License#
Insulation Contractor Information
Insulation Inc. 919-772-9000
Insulation Contractor's Company Name&Address Telephone
*NOTE:General Contractor must fill out and sign the second page of this application
Sprinkler Contractor Information
Sprinkler Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s)of Corporation License#
Fire Alarm Contractor Information
Fire Alarm Contractors Company Name Telephone
Address Email Address
Signature of Officer(s)of Corporation License#
Driveway Access- NC Department of Transportation Driveway Access/Permit? __. Yes No
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 if my 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 charged at full price per current fee schedule.
Signature of Ow r/Contra or/ icer(s) of Corporation Date
Affidavit for Worker's Compensation N.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 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 worker's compensation insurance prior
to issuance of the permit and at any time during the permitted work from any person,firm or corporation
carrying out the work.
Company or Name:,,,
Sign w/Title: ;�t""!� Date: 4 //), /&