BUILDING
71
Harnett County Central Permitting
PO Box 65 Lillington, NC 27548
Telephone Number 910.893-4759
~nJ A Ilcatlon for uildin and Trade Permit
Owne s Name: / ' L/P ._a~i~ e Date: - O
Address: Phone:
Directions to job site: rr
Subdivision: fut of ~i1As•f , e0Ac1S Lot: 'Sl
Construction Type: (Please Check) Building Use: (Please Check)
_ New _ Residential
Renovation _ Modular
yMdition _ Commercial
_ Moved House _ Multi-Family
_ Other
D r
escription of Propose Wor k/ LSR%c/< r LO QQ 0Ao •
Total Project Cost: 1100
Building Permit Information ~d o
Heated SF _Crawl Space O Building Construction Cost $
Unheated SF Slab Acres Disturbed Stories
C%n✓arr SetiS CEyp(A. 9/9 g7r
Contracts ompany ame Telephone
dress License #
i nature of Officer(s) of Corporation
Electrical Permit Information
Description of Work Electrical Cost $
TS Pale: Yes() No Underground Overheard ( )
Permanent Service: Underground Overhead Service Size: Amps
Electrical Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Mechanical Permit Information
Description of Work
Number of Units Type System Mechanical Cost $
Mechanical Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Plumbing Permit Information
Description of Work
Number of Baths Plumbing Cost $
Plumbing Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Insulation Permit Information
Residential Other Not Required ( )
Insulation Contractor's Company Name Address Telephone
Page 1 of 3 12/04
k
Sprinkler System Information
Sprinkler Contractor's Company Name Telephone
Contact Person
Address License #
Signature of Officer(s) of Corporation
Fire Alarm System Information
Fire Alarm Contractor's Company Name /j Telephone
Contact Person
Address License #
Signature of Officer(s) of Corporation
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 any changes occur
including listed contractors, site plan, building and trade plans, Environmental Health permit
changes or proposed use changes, I certify it is my responsibility to notify the Harnett County
entraI Permitting ivision of any and all changes.
-
Sig ature of Owner/Contractor/Officer(s) of Corporation Date
Page 2 of 3 12/04
Affidavit for Worker's Compensation
N.C.G.S. 87-14
The undersigned applicant for Building Permit # being the:
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/have three (3) or more employees and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more subcontractors(s) and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1) or more subcontractors(s) who has/have their own policy of
workers' compensation insurance covering themselves.
Has/have not 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.
Firm Name: ' 1`MQ --,P
Byrritle: p
Date:
it
Page 3 of 3 12/04