BUILDING
whomever performing work. Must be owner Application # (y0~~ '~l I
or licensed contractor. Address, company
name & phone must match information on Harnett County Central Permitting
license. PO Box 65 Lillington, INC 27546
910-893-7525 Fax 910-893-2793 www.hamen.org/permits
Application for Residential Buildina and Trades Permit
Owner's Name: C(Mt0CD11) Lt LG(; Date:
Site Address: I E wi,~n ,¢d f7E_a ®e Phone: 91D W6 -Wz; 9'
Directions to job site from Lillington: Nu) l/ a 7 , 0 04) 4S'&-eV Xd TU,OV Crr'7
1'3~OLGOC,! 70 /r I/ V 74)1?AJ CEf7-q d~OLCOuJ TU 4N0614fON CAGE/[ JW.
Subdivision: 4A)0C/S0N0_12e_E1( CGUB Lot:
Description of Proposed Work: NeWf,_I)G~e ~Qrn•I /~oirle #Bedrooms: 3
Heated SF D a D Unheated SF ~ 00 Finished Rec Room? 4 C~ _ Crawl Space Slab
General Contractor Information
//o: CD.US72UCr02S, /,{/G 9i0-~/f6 -y`dc/
Building Contractor's Company Name Telephone
q/4 betE2E7 4)C)0)9dyc- S/e el-P0 FA4,vC-)6av i ~ls5y-U
Address 1 I k 'I License #
'MaAk. I Must sign & fill out second page
Signature of Owner/Contractor/Officer(s) of Corporation
Electrical Permit Information
Description of Work Electrical Cost $
TS Pole: Yes No Underground Overhead
Permanent Service; Underground Overhead Service Size: Amps
Tt 0 Elect l~ Coy, E. G 10 .
Electrical Contractor's Company Name Telephone
Ant Sw11~ca~r NS3la as333 U
_ License #
i
Stgnattae of Officer(s) of C
work Aieal Permh rnr .a
f' y p ~i Number of%W
i vT-Mare t e mad Cost 5
5ComP¢RYNama - t -h cld tJ(' '+ryT*T^-
Stgoaatra of car(s) of Corporation 1 { # ) 3 T • O pO
Tetephooe
I
Pfim-bm,- Persa2 3afezmaRen
Desa;ptim of Wodc Nth of Baths Phnsb~ Cost S
VANCE JOEWSON PLT) IBP G 3242 NED PL~ri D1L FAYETTEVILU, NC 25306
/P' ~ s any Name Address
07756 PI 91# 414b712
Si ;ah of cars € era -w Licerse # Telephme
Signature of Officer(s) of Corporation
~r Insulation Permit Information
kr'fDAfy .%/C/ ti(~ Jdj0/ 9/O- ~6G ~kPST
Insulation Co tractor's Company Name & Addres Telephone
I
8/21/08
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 Exemption.
Questionnaire per G.S. 87-14 Regulations as to Issue of Building Permits (Memo available upon request)
i
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 anage construction of the
project? - yes -no
3. Do you intend to directly control & supervise strufi ction activities? _ yes _ no
4. Do you intend to schedule, contr or directly pay for all phases of construction work to be
done? - yes - no
5. Do you intend to onally occupy the building for at least 12 consecutive months following
completion of comer struction and do you understand that if you do not do so, it creates the
presumptionxmder law that you fraudulently secured the permit?
j _ yes _ no
1 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,
number of bedrooms, building and trade plans, Environmental Health permit changes or proposed use
changes, I certify it is my responsibility to notify the Hamett 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 current fee schedule.
„Gi~UnwU 7 U ~I-23-01
Signature of Owner/Contractor/Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87-14
The undersigned applicant being the:
General Contractor X 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.
A Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance
covering themselves.
I
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.
~'D~(JlTCUC~QiCS, `er/C
CompanyorName: Z411
Sign w/Title:~V (AL VAV-- /P&-1/1j1//i/1GL/N/r4i /7 a/eiDate: y-23-00?
8/21/08