BUILDING
JUN-19-2006 11:32 ADULT PROTECTIVE SERVICES 910 677 2656 P.02
Harnett County Central vermlmmg
PO Box 65 Lillington, NG 27546 /5N5
Telephone Number 910-993-4759
A lication If r Buildin and rade Permit
Owner's Name:~r - Date: 60
'
Address: one
D' ions o jo site:
Axe
f a 0l~ Lot:
~Su division:
dnst i n e: (Please Check) B ildin Use: (Please Check)
ew Residential
Renovation _ Modular
_
Addition - Commercial
-
_ Moved House - Multi-Family
Other
Description of Prop w rx: Ga [t
Total Project Cost:
Building Permit Information
Heated SF. ` Crawl Space O Building Construction Cost $
Unhe Acres Disturbed Stg *a
Buildina D~nn~i r,a~d~a}rs Cp pony Name ' TelephoneP L r CSL/1S L-
$ Luc rr
Addr License #
Signature of Otfie r(s) of Corporation
Electrical Permit Informati
Description of Work Electrical Cost $
TS Pole: Yes ( ) No ( Underground Overheard ( )
Permanent Service: Underground O Overhead O Service Sae: Amps
Electrical Contractors Company Name Telephone
Address License N
Signature of Officer(s) of Corporation
P rmit I formation
Mechanical
114- Description o' Work Type System Mechanical Cost S
Number of Units
Telephone
Mechanical Contmctor's Company Name
Address License 0
Signature of Officer(s) of Corporation
Plumbinn Permit information
Description of Work plumbing Cost $
Number of Baths
Plumbing Contractor's Company Name Telephone
Address License #
Signature of officer(s) of corporation
insulation Permit Information
Residential ( ) O I er ) Not Required ( )
Address Contractors Company Name Telephone
page 1 of 3 12104
JUN-19-2006 11:32 ADULT PROTECTIVE SERVICES 910 677 2656 P.03
Sprinkler System Information
Sprinkler Contractors Company Name Telephone
Contact Person
Address License #
Signature of Officer s) of Corporation
Fire Alarm System Information
Fire Alarm Contractors Company Name Telephone
Contact Person
Address License #
Signature of Officer(s) of Corporation
Driveway Access
NC Department of Transportation Driveway Access/Permit? Yes- Noz
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 Hamett County
Central Permitting Divisi n of any and all changes.
Signature of OwnerlCo raclorlOtTcer(s) of Corporation Date
Page 2 of 3 12/04
JUN-19-2006 11:33 ADULT PROTECTIVE SERVICES 910 677 2656 P.04
Affidavit for worker's Compensation
N.C.G.S.87-14
The undersigned applicant for Building permit p 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.
Hasfhave one (1) or more subcontractors(s) who hasihave their own policy of
workers' compensation insurance covering themselves.
`/Has/have not more then 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 carryi g out the work.
Film Neme:
BY/Ttie:
Date: ~~!1Q
Page 3 of 3 12104
TOTAL P.04