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DOCUMENTS 00/09/11 Application# Harnett County Central Permitting 1455 00 3`7t1 Each section below to be filled out PO Box 85 Lillington NC 27546 910 893 7525 Fax 910 893 2793 www hamett org/permits by whomever performing work Must be owner or licensed contractor Address company Application for Residential Buildina and Trades Permit name&phone must match Owners Name T)O r te\ f Kr- hG JC\ Date �, /f�i Site Address tT►��cf rTr, ��� Phone 9161- 1-3953 Directions to job site from Lillington (`J cri\-v CA) 00 CZA (a(a,vi.)% Sqlthc 0 o40 t■ C-27 kJ (Y1.1 rnt) ) L�J oc o N3L 21-4 NG-27 w (O 't cn•) j ©n� Urn on 're Q A Subdivision NyA -tot "Traces 2- Description of Proposed Work IJP W S #of Bedrooms Li Heated SF 3- Unheated SF ((PH Finished Bonus Room' 0 Crawl Space .�Slab General Contractor Information, � �O. S o c. R1q-7214 -4-g-t Building Contractors Company Name Telephone sr 2- W WxrAA mod r te /J C 270-1 teogs L.rn acinerhoone3.com Address Email Address G$ C.o2 License# • r, •r 1 •1u1 _ • Description of Work EI494 -roc sF1 Service Size OD Amps T-Pole XlYes No c* L.-av\rir �Iec � c 1?9- 23-Co'Z4D(o Electr ontractor s Company Name Telephone I l'LO ma. 2 +�l C 2-7 .3 9 vee�i @ nehe,c . cc� '■ Address ) Email Address License# Mechanical/HVAC Contractor Information Description of Work ON& nn A k t rt ?s Pli� & i r roA iki on i, q(q--77,r_revo Mechanical Contractor s Comp n Name Telephone 42° Da VCo1,e .�tei NC 27(o 10 ;„nbeA �C�,�r-ma ems,,.ccr/ Address 1 V I Email Addriasi q9 License# Plumbing Contractor Information, Description of Work -PI ut(Y1b\(\ ��c NCLtJ #Baths `5 A< -tY\a u ?\ \bi c q/q-(07 -011 Plumbing Contractor s Compan ame Telephone 02 Pc-03 r\ i Apex, JC 2-7539 a(1-rrrycpt,PeA1Di .<<:�, Address Email AdAress 29027 License# Insulation Contractor Information IrNs1/4.)1a'6 1`x-`1`72_—(1000 Insulation Contraetas Company Name&Address Telephone *NOTE General Contractor must fill out and sign the second page of this application I hereby certify that I have the authonty 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 pv sianina 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 permit re-issue fee is$150 00 After 2 years re-issue fee is r current fees • •ule x in Date Si atur f Owner ontractor/Officer(s)of Corporat o ate Affidavit for Worker's Compensation N C G S 87-14 The undersigned applicant being the X 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 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 work Company or N= e . A E._ 1 •ski t Z K C. Sign w/Title /V! A.; ens_ COXck 01 Date OP ID:CV ACORD' DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/09/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maconachy-Stradley Insurance PHONE FAX 3205 Bretton St.NW Suite 100 (A/C,No,Ext): (A/C,No): _ North Canton,OH 44720 E-MAIL Robert D.Stradley PRODUCER CUSTOMER ID N:SCHUM-1 _ INSURER(S)AFFORDING COVERAGE NAIC M INSURED Schumacher Homes of INSURER A:Cincinnati Insurance Co 10677 North Carolina,Inc. 2715 Wise Ave NW INSURER B: Canton,OH 44708 INSURER C: . INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER IMMIDDIYYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP0890539 01/0112015 01/01/2016 DAMAGET PREMISES S((Ea REN occurrenceED ) $ 500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 1,000 PERSONAL 8 ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000 (Ea accident) A X ANY AUTO CPP0890539 01/01/2015 01/01/2016 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS X HIRED AUTOS PROPERTY DAMAGE (PER ACCIDENT) X NON-OWNED AUTOS $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 A — CPP0890539 01/01/2015 01/01/2016 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X TORY LIMITS ER Y/N A ANY PROPRIETOR/PARTNER/EXECUTIVE WC185996904 04/1312015 04/13/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION FORINFO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Robert D.Stradley ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 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 l le C-�L on4 (om.ar)� Mailing address of Agent \ (1 U) , c kr( J .1e c, NL- 2-762D Physical address of Agent �c 'e c-k< Telephone - C n RQ-c7 3 ail Fax q I L-1 g'q-5 2 3 I Email ,6, *G�G I Len5n P off\ 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 permit 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 DO NOT REMOVE! Details: Appointment of Lien Agent Filed on: 11/09/2015 Entry #: 377884 Initially filed by: schumacherhomes Designated Lien Agent Project Property Print & Post Stewart Title Guaranty Company parcel ID#is 09-9564-0111 Hillmon Grove Road ❑ 47 - ❑ Cameron,NC 28326 . AddreesWl9 W1GHa c Hargett Stn,Suite S0 r8 507/Raleigh, Harnett County }r,a. . f4;,x NC 27601 El •> _ Phone:888fi90-7384 Property Type Contractors: Fax:913-489-5231 Please post this notice on the Job Site. Email:sunoortnliensne.eom ,. 1-2 Family Dwelling Suppliers and Subcontractors: Scan this image with your smart phone to view this filing.You can then file a Notice Owner information Date of First Furnishing to Lien Agent for this project. Daniel Foucher and Dawn Bishop 11/30/2015 7421 Pine Summit Drive Fuquay Varina, NC 27526 United States Email:ixdaniel wmac.com Phone:919-561-8953 View Comments(0) Technical Support Hotline:(888)690-7384