DOCUMENTS Initial Application Date( 0O•+p 1 l U Application# sis 3 `
L Ctl#
COUNTY OF HARNETT RESIDENTIAL LAND USE APPUCATION
Central Permitting 108 E.Front Street,Lillington,NC 27546 Phone:(910)893-7525 ext:2 Fax:(910)893-2793 www.hamed.orglpermits
"A RECORDED
D SURVEY MAP,RECORDED D(OR OFFER TO PURCHASE)&SITE PLAN ARE REQUIREDREUIMIEN SUBMITTING A LANDUSEAPPLICATION"
LANDOWNER: CI la�I 0. � fkil I n Mailing
�Address: -�I/1 141( kif i TIO' .
City: Y(el �L((//(''p,•f \�Ja(JIAc_- State:N` Up: Contact No'I(q s oa-(p ?Email:
APPLICANT':CS l a4 NC- L.LC_ Mailing Address: 2300 &J (A S 1
City: ')'[�yy,�//. state:N C Zip.Xre -contact No: a(Cl 3(07-RJflEmail: er j Coo 110nnls h Q.C cw)
'Pleased out avpxent information It different than landowner ' 1� �� �..0,�.1\'� (� r� �I ^�
CONTACT NAME APPLYING IN OFFICE:C.Ve`er L,-r-❑e Phone# -1(-1 3.0-1---)a-).--)
•
PROPERTY LOCATION:
Subdivision: ^ Lot#: ✓ 'L1ott Size: L0 `� T/
State Road# 1-2150 State Road Name: 1 lQ rdf Map Book&PagaCCO , ¶3l b
Parcel: U &C>4. St/�DI L-1 I rao(� INN, e
Cp 94- `6 - i n 143 •0( ti\
Zonin Flood Zone\lC- Watershedy�Deed Book&Page?O 1 / / ft Power Company:
'New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
PROPOSED USE:
Monolithic
❑ SED:(Size_x )#Bedrooms:_#Baths:_Basement(w/wo bath):_Garage:_Deck:_Crawl Space: Slab:_Slab:_
(Is the bonus room finished?( )yes (_)no wl a closet?(_)yes ( )no(i yes add in with#bedrooms)
❑ Mod:(Size x )#Bedrooms #Baths_Basement(w/wo bath)_Garage:_Site Built Deck:_ On Frame_Off Frame
(Is the second floor finished?(_)yes ( )no My other site built additions?( )yes ( )no
❑ Manufactured Home: SW DW TW(Size x )#Bedrooms: Garage:_(site built?_)Deck: (site built? )
❑ Duplex:(Size x )No.Buildings: No.Bedrooms Per Unit
❑ Home Occupation:#Rooms: 'y Use: Hours of Operation: #Employees:
❑ AddAddition/Accessory/Other.(S�izee x�1 )Use: k.✓t9r�V� clot lo(vitni4. y Phi-�/�) Closets in addition?( )yes (_)no
Water Supply: County Existing Well New W
ell(#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 (_)no
Does the property contain any easements whether underground or overhead( )yes ( )no
Structures(existing or proposed):Single family dwellings: Manufactured Homes: Other(specify):
Required Residential Property Line Setbacks: Comments:
Front Minimum Actual �i{�
Rear .
Closest Side l0
Sidestreet/comer lot
Nearest Building 1)
on same lot
Residential Land Use Application Page 1 of 2 03/11
APPLICATION CONTINUES ON BACK
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON:
Kor$. YY�n s- l� , M aAct n n�ecn [u� L. t-l5 �{'0 I�
t R12 ,-P5 Cjw rci , 1/21UorUJ
If permits are granted I ag to conform to all in; ces aQd I, the State of North Caroline roguish g such work and the specifications of plans submitted.
I hereby stale that foregoin laments irere I..nd .us•s. S,the beet of my knowledge. Permits lett to revocation it false Infamatbn is provided.
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Signature of Owner• ent Date
•
'it Is the owner/applicants responsibility to provide thcounty with any applicable atlon about the subject property,including but not limited
to:Eoundary In anon,house location,underground
etc.und or overhead easements,etc.The county or Its employees are not responsible for any
incorrect or missing InfornaHoS,that Is contained within these applications."'
"This application expires 8 months from the initial date if permits have not been Issuer
Residential Land Use Application Page 2 of 2 03111
NAME: Cf•Del\ PrcAs 3c LLC- APPLICATION#:
*This application to be filled 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 plat=without expiration)
910-893-7525 option I CONFIRMATION#
Environmental Health New Septic SvstemCode 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 Existing 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 indicate desired system type(s): can be ranked in order of preference,must choose one.
{ } Accepted 1_) Innovative I_I Conventional (_l Any
{ } Alternative (_1 Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answ is"yes",applicant MUST ATTACH SUPPORTING DOCUMENTATION:
{_}YES { Ng Does the site contain any Jurisdictional Wetlands?
{ }YES (LI Np' Do you plan to have an irrigaton system now or in the future?
(_}YES I Does or will the building contain any drains?Please explain.
{ }YES I Are there any existing wells,springs,waterlines or Wastewater Systems on this property?
(_LYES { Is any wastewater going to be generated on the site other than domestic sewage?
(_)YES ( �i0 Is the site subject to approval by any other Public Agency?
1_}YES I 1 NO Are there any Easements or Right of Ways on this property?
(_}YES (_I NO Does the site contain any existing water,cable,phone or underground electric lines?
If yes please call No Cuts at 800-632-4949 to locate the lines. This is a free service.
I Have Read This Application And Calif That The Information Provided Herein Is True,Complete And Correct. Authorized County And
State Officials Ar- . ante. Right Of En y To onduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Undersea r I het I Am S.II(,,• y R ' C Fo The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site bl So T I Corn M.- alien Can ;e Performed.
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PROPERTY OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) DATE
10/10
3Eo Ot llorel Rid
R9wy Valuta-, N c 2-1c2J-.
7.
SITE PLAN APPROVAL 1/��,A
DISTRICT_-USE` {>�
#BEDROOMS _
ar t
htPO e
sboc,Fr
ode deck 7ilib
lik"
t?2p0Eed
3' ji1 .
IVr9roi.�d F1^'Jbsf
Swru.m;.3- Pool
P^Poal .Pevw
io Ic pod code
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NTE# o-s-zsz6 Harnett County Department of Public Health
PERMIT # 7J,a09.0Operation Permit 21 7 3 6
"New Installationeptic Tank Nitrification Line 0 Repair 0 Expansion
PROPERTY LOCATION:3144r.ta F,h//t/.aai'a
Name: (owner)(�/!42-4 '{'frogs LZ/v•uc-1 SUBDIVISION LOT # (
System Installer. AL 4h" Registration #
Basement with plumbing: 0 Garage f/ttumber of Bedrooms
Type of Water*pig 0 Community fd Public 0 Well Distanapfrom well feet
System Type:fl%TPr�ierakti 1 arig—rypm-�Cu &' / Types V and VI Systems expire in 5 ran.(In accordance with Table Y a) / Owner must contact Health Department 6 months prior to expiration for permit renewal.
This system has b.,i instaled in compliance with aplAioble North Carolina General Somm,LIE for Saage fre Ent and Disposal,and at condition;el the Improvement Penrit and Comnuctien Aunonotia.
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PERMIT CONDmONS:
I. Performance: S m shall perform in accordance with Rule .1961.\ 1
II. Monitoring. As required by Rule .1961.
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III. Maintenance: As required by Rule .1961. Other.
Subsurface system operator required?Yes 0 No 0 —
If yes,see attached sheet for additional operation conditions, mainCrenance and reporting.
IV. Operation:
Y. Other.
0 D-Box 0 Pump 0 Alorm 0 HMOline 0 PWR line
Following are the specifications for the seamy disposal system on the above captioned Finery 6
Type of system: 0 Conventional EM Other ,'i. I . •,. .a.. r pdc Tank: Yob gallons Pump Tank gallons
Subsurface No. of exact length width of .., depth of
Drainage Field ditches 1 of each ditch 106 feet ditches ket ditches ZZ.I 18 inches
French Drain Required: gLinear feet
Authorized State
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09109/11 Application#
Harnett County Central Permitting
Each Becton below to be Med outPO Box e5 on NC 27548
by whomever Performing work
910 893 7525 Fax 910 88833 2 27783 www named rag/permits
Must be owner or licensed
contractor Address company Aoohcation for Residential Building and Trades Permit
name 8 phone must match 1
Owners Name 1<l1,19 DGlrtts2 Date (p/22l1$
Site Address 3So I14.-P( teed l FIA ottf ✓ifvinn�— Phone `1ler- s52-lnas2
Directions to job site from Lillington 1 Ynnt Gi O V3 l O H in St.I onto
4rX-1nruw PIS-wy.� onto Us- Ll-0l I nnim 12-curls
C-hA rtIn Rd -on-ho 1-1illi a rd 12-c1 .
Subdivision 9 q Lot
HeatedDescription
Sof Proposed UnWorkd SF X 11 F is BIA R m5vf)ur4l Vans Bedrooms pace Slab _
General Contractor Information
Cnn( Pnnls t\r, 1 iG g1e1 3co-1 12l"1
Building Contractors Company Name Telephone
too DIOk us I tflr.ly I Pp-ex. Gl-evtt@c.00lptblsnC.tDnn
AddressN6Z-i S o Z Email Address
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License#
I' r Ian
Description of Work EC 11 pin n7,VA 42 Service Size _Amps T-Pole _Yes_No
Ag-C 6IRG-4vtc. . n glcf- S`6'3 - 3GDO
Electrical Contractors Companl Name Teleph ne cu��
P.p-Box5a-&ss I F-a Lely In NO 27coE °lt AUa+rtercorY\
Address Email Address
2116 C95 I--
License#
MechanlcaUHVAC Contractor Information
Description of Work
Mechanical Contractors Company Name Telephone
Address Email Address
License#
plumbing Contractor Information
Description of Work #Baths
Plumbing Contractors Company Name Telephone
Address Email Address
License#
Insulation Contractor 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 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 p unit re-issue fee is$150 00 After 2 years re-issue fee
is as per current fee schedule
o/v2/127
Signa er/Contractor/Ofhcer(s)of Corpo ion Date
Affidavit for Worker's Compensation NC G S 87-14
The undersigned applicant being the
VGeneral Contractor _Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) firin(s)or corporation(s)performing the work
set fort 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 pnor
to issuance of the permit and at any time dunng the permitted work from any person firm or corporation
carrying out the work �
Company or Name CpoI POOLS IVC
Sign w/Tid /e C c Date W I //QJ
Application#
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546 - Ph:910-893-7525 - Fx:910-893-2793 - www.hamett.org/permits
Certification of Work Performed By Owner/Contractor
'(individual Trade Application)
Owner(s)of Structure: L it03 tom. Phone: eil"1 G5a (QQa
Owner(s)Mailing Address: Sco Ur, ora K(Y
c'ttrti1Gt1 OClflAF_
Land Owner Name(s): Sgvn-e Phone:
Construction or Site Address: SIX WI`P
PIN# pp Parcel#
Job Cost D(DM . Description of Work1
to be done -rc AC U p ce I {if o m p `L
(�
I E D I kr/Pt 10141 A6 Q retAng pca\
Mechanical: New Unit With Ductwork_ New Unit Without Ductwork_ Gas Piping_Other
Electrical': 200 Amp <200 Amp_Service Change_ Service Reconnect_ Other
'For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap Number of Baths Water Heater•
Specific Directions to Job from Lillington:
Subdivision:cbI -T- Lot#:
I C Kerki C A-!x0 will provide the EPI2C.i-fl C, labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is ,which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code and all
other applicable State and local laws,ordinances and regulations.
�{'f `�62C�1'CI c- TAO ___91.5_222):2_"
Contractor's Company Name Telephone
.0 . Sic,7c 522SS Pea t cus-Ern1-ercafe. Qarcelec -tc.,
AddressG/-c ��� Email Address• C
act �t6/ '_ L- a
License# ^1 pp
Structure Owner/Contractor Signature: Date: J LOWof cc, ao( CJ
By signing this application you affirm that you have •brained permission from the above listed license holder to
purchase permits on their behalf. If doing the work as owner you understand that you cannot rent, lease or sell
the listed property for 12 months after completion of the listed work.
*Company name, address, & phone must match information on license
HARNETT COUNTY CASH RECEIPTS
mxx CUSTOMER RECEIPT xxx
Oper: MOCK Type: CP Drawer: 1
Date: 6/25/1B 52 Receipt no: 400916
Year Number Amount
2010 58844346
91749 TECH 2
LILLINSTON, NC 27546
B4 BP - ENV HEALTH FEES
1100.88
EXT TANK
COOL POOLS
Tender detail
C8 CHECK PAYMEN 5256 $100.88
Total tendered 4108.00
Total payment $100.88
Trans date: 6/25/19 Time: 14:34:191.
1
ex THANK YOU FOR YOUR PAYMENT x+