BUILDING • Each section below to be filled out by /9 g--4 2 L /f
' , 7
whomever performing work. Must be owner Application # /
or licensed contractor. Address, company Harnett County Central Permitting
name & phone must match information on
license. PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
1
1 Application for Residential Building and Trades Permit
j� -4 Owner's Name: Lct t` 4 Bc r; :.1g ( ; ISOh1 Date: $X d
�✓ Site Address: l 3‘ R ey4l f t, C eS 1- 0 r Phone:
Directions to job site from Lillington: 5'o / Nor }k {} t o N C tit` 1 s 4r a r
Light Rd L7 oN R;uer Rcl R7 on Regal -
(rrs nn
Subdivision: tke94I Cre.S`r r el f L ot: ( (
Description of Proposed Work: RPS t77C r i Ce #Bedrooms: q
Heated SF or Unheated SF Finished Rec Room? ' Crawl Space (krSlab ( )
General Contractor Information
£eki nlrS NLnc.1ri,J 919 #I'1 -91
Building Contractor's Company Name Telephone
sa'i Ctif sl kn.) Lit* Rd P1oay N L a9tia I
si ss _ aia‘ License #
. oNiAL (r� r Must sign &fill out second page
ignature of Owner /Coctor /Officer(s) of Corporation
Electrical Permit Information
Description of Work ' W i f, ( j H ot Y2 Service Size: Lin° Amps TPole: &no
Hri;r Fec ±riC 1 v,( Telephone
1 — 3�( — ,24
Electrical Contractor's Company Name
2I i, � 37a
n • ess License #
r : I. � r 1,t'L V P
. ignature of 0 icer(s' of corporation
Mechanical /HVAC Permit Information
Description of Work 1.1 rtJ 1:43(4.5e
e 1. . <- - ° 41- r -_ G• 9(9 &j BOTO
Mechanical Contractor's Company Name Telephone
■Rei QCO Poxes Ra4,rD, ST //b /EJ(1G+~K A9 z7 61 0 ,75
A dre r / License #
Vr
Sig lure Offi r(s) of Corporation
Plumbing Permit Information
Description of Work NCw ( -1ouSC # Baths `? ���
I) t V - �et..;.. o
Plumbing Cntr to s Company Nam Telephone
13488 gc. er&r si 4 F V iv/ rd.
Addre License #
K flh IL—
Signature of Officer(s) of Corporation
Insulation Permit Information
-- rt..1 SOLI cc4irrs 'Lac r1'9Q 9Oo-o
Insulation Contractor's Company Name & Address Telephone
■
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)
1. Do you own the land on which this building be constructed? — yes no
2. Have you hired or intend to hire an individual to superintend and manage construction of the
project? - , ' t _ yes no
3. Do you intend to directly control & supervise construction activities? _ yes _ nb
4. Do you intend to s chedule, contract, or directly pay for all phases of construction•work to be
done? _ yes _ no
5. Do you intend to personally occupy the building for at least 12 consecutive months following
completion of construction and'doyou 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 Hamett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and if m 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 76 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
i per current fee schedule.
li FJ l p�4t/K / / �( r
6 -I - /0
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 Owner / Officer /Agent of the Contractor or Owner
Do hereby confirm under 'penalties of er'u that the 'ersori s ,'film s or c dY or'ation s
y p 1 ry p O O p Operforming the work
set forth in the permit: - -
Has three (3) or more employees and has obtained workers' compensation insurance to cover them.
1 one (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover
them. '
t/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: (....\
Company t..4 1.i �.f lr 5 (} N c L 0. to r I N
Sign w /Title: IS- Qtv\1v Y '[ c FO- + -vu^^' ° Ner Date: s 6 "l 0
8/21/08