BUILDING Each section below to be filed out Application #
by whomever performing work Harnett County Central Permitting
Must be owner or 1 tensed PO Box 65 Lilbngton NC 27546
contractor Address company 910 893 7525 Fax 910 893 2793 www harnett org/permits
name 8 phone must match
Application for Residential Building and Trades Permit
Owner s Name C M 61 . . d'l O Date 343/4/
Site Address w o q C! v , , rtVt 4 '� jt e. Phone 6 — 73c/
Directions to ob site from Llllington vv
0 • - 1 1 /a WillEgn o
/Airy S 4c
Subdivision Lot
Description of Proposed Work Roan - ' # of Bedrooms
Heated SF Unheated SF //n Finished Bonus Room/ Crawl Space ft__ Slab yt'.S
General Contractor Information
C \ A -C . w\ n4 U„ L.) V �.
lcl L.. S 9/9 4/64) - 10&3 Z
Building Con or s Company Name Telephone f
So `JO rn -, €' f Mt r. S \ L rattt . per r C kc wip%r.,. <c>L \l II lc&
••• -SS mailAddr�4SSs I Orr-
-.
ems 61/4 9 Z
• - r -e of Owner/Contractor/Officer(s) of orporation License #
Electrical Contractor Information
Description of Work 0 7 rot A S Service Size Amps T Pole _ Yes A
' 6u' 9/9 a to / _ f, R/ 5'
Electrical « ontr c Company Name Telephone
Tr•L. owcr S9,9 1 sr.).,. s ?G rrp Cali 4.
Address - s Email Address
c 4 , —ta a c9O / 0
Signature of Owner /Contractor /Officer(s) of Corporation License #
Mechanical /HVAC Contractor Information
Description of Work /�n
Mechanical Contractor s Company Name Telephone
Address Email Address
Signature of Owner /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work 7 / /� # Baths
Plumbing Contractor s Company Name Telephone
Address Email Address
Signature of Owner /Contractor /Officer(s) of Corporation License #
Insulation Contr. tor ,L' ormation
Insulation Contractor s Company Name & A dd e- Telephone
NOTE General Contractor must fill out and sign the second page of this application
H 1 I d I y Appl at I 2 08 10
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you qualify for permit under Owners E emotion
Questionnaire per G S 87 14 Regulations as to Issue of Building Permits (Memo available upon request)
1 Do you own the land on which this building will be constructed? _ Yes _ No
2 Have you hired or intend to hire an individual to superintend and
manage construction of the projects _ Yes _ No
3 Do you intend to directly control & supervise construction activities? _ Yes _ No
4 Do you intend to schedule contract or directly pay for all phases of
construction work to be donee _ Yes _ No
5 Do you intend to personally occupy the building for at least 12 consecutive
months following completion of construction and do you understand that if
you do not do so it creates the presumption under law that you fraudulently
secured the 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 a� 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 as per c rrent fee schedule
Signature o •w er ractor /Officer(s) of Corporation Dat
Affidavit for Worker s Compensation N C G S 87 14
The undersigned applicant being the
A General Contractor Owner Officer /Agent of the Contractor or Owner
Do hereby confirm under penalties of per jury 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 4 ^ • C
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�� CERTIFICATE OF LIABILITY INSURANCE OP ID KF DATE(MMIDDIYYYY)
11/23/10
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 IA 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(les) must be endorsed If IS WAIVED subject to
the terms and conditions of the policy certain policies may require an Indorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s)
PRODUCER 4UNIALI
NAME
Roeding Insurance Agency (A , Eat) (NC N I
2734 Chancellor Dr ADDRESS
Crestview Hills KY 41017 CUSTOMER ID# CHAMP -
Phone 859 - 341 -0202 Fax 859- 341 -3709 INSURER(S) AFFORDING COVERAGE NAIC#
INSURED INSURERA OHIO CASUALTY 24074
Champion Window Company of INSURERS INDIANA INSURANCE COMPANY 22659
Raleigh Durham LLC
300 Dominion Drive #201 INSURERC Sentry Insurance
Morrisville NC 27560
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 CONT CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLI IES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDU TED BY PAID CLAIMS
t
LTR TYPE OF INSURANCE N9R WVD H
POLICY NUMBEi ULWY SF YULN.YGXY LIMITS
(MMIDDtflYY) (
GENERALUABILRY EACH OCCURRENCE $1,000,000
A X COMMERCIAL GENERAL LIABILITY BKA53758486 12/01/10 12/01/11 P REMISES (E t occu U nce) 3100,000
CLAIMS-MADE I X I OCCUR MED EXP (Any person) S 10 000
PERSONAL BADV INJURY $ 1 000 , 000
GENERAL AGGREGATE $ 2 000 000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS COMP /OPAGG $ 000 , 000
n POLICY n riNy 1 X I LOC $
AUTOMOBILE LIABILITY t COMBINED SINGLE LIMIT 31 000 000
(E cad M)
A X ANY AUTO BAA53758486 1 12/01/10 12/01/11 BODILY INJURY (Per per ) $
ALL OWNED AUTOS BODILY INJURY (P cold° t) $
SCHEDULED AUTOS 1 PROPERTY DAMAGE
A X HIRED AUTOS BAA53758486 12/01/10 12/01/11 (Pe'e°CMern) $
A X NON -OWNED AUTOS BAA53758486 12/01/10 12/01/11 _ $
$
B UMBRELLALIAB X OCCUR CU8319330 12/01/10 12/01/11 EACH OCCURRENCE $ 10 000 000
EXCESS MB CLAIMS AADE AGGREGATE $ 10 000 000
DEDUCTIBLE s
s
C WORKERSCOMPENSATON 0 90162320100061 12/01/10 12/01/11 X ITORYL I IMTIS I
AND EMPLOYERS LIABIUTY
ANY PROPRIETORPARTNERIEXECUTIVU NI EL EACH ACCIDENT $ 1 000 000
OFFICER/MEMBER EXCLUDED?
(M d t ry l NH) E L DISEASE EA EMPLOYEE 31
e ea de aenlle Vl der EL DISEASE POLICY LIMIT $ 1 000 000
DESCRIPTION OF OPERATIONS bel w r
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Arta h ACORD 101 Additional Remark 9 hedul M more pa M required)
CERTIFICATE HOLDER 1 CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PRESENT THE EXPIRATION DATE THEREOF NOTICE WILL BE DEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS
PRESENTATION ONLY
AUTHORIZED REPRESENTATIVE
Marc Teasel
XXXXXXMODOCXXXXXXXXXXX XX XXXX3CCOODC
I 01988 2009 ACORD CORPORATION All rights reserved
ACORD 25 (2009109) The ACORD name and logo arelregistered marks of ACORD
1
Plan Box Number /1 �i Job Name a) Vi p,/ 0/2 W
Date 3 - �4 — /1
Required Inspections for SFA/SFD
Appl # � S 90 2 ,626 0
Valuation 47 /q ?
Sq Feet p /0
Sequence
10 R* Bldg Footing
10 R* Mono Slab
10 30 R* Elec Temp Service Pole lK/`
20 Foundation Survey 41,; r>4
20 R* Building Foundation
20 Address Confirmation Slab
30 999 Open Floor
30 999 R* Bldg Slab Insp Mono
30 999 R* Elec Under Slab
30 999 R *Plumb Under Slab Crawl
40 Four Trade Rough In
40 Four Trade Rough In> 2500
40 Three Trade Rough In
40 Three Trade Rough In> 2500
40 Two Trade Rough In
40 Two Trade Rough In> 2500
40 One Trade Rough In
40 One Trade Rough In > 2500
50 R* Insulation
60 Four Trade Final
60 Four Trade Final > 2500
60 Three Trade Final
60 Three Trade Final > 2500
60 Two Trade Final
60 Two Trade Final > 2500
60 One Trade Final
60 One Trade Final > 2500
999 Envir Operations Permit