REVOKED TRADE APPLICATION FROM :COMFORT WIZARDS HTG /AIR FRX NO. :9196623050 Apr. 20 2010 03:20PM P2/3
• Each section below to be filled out by
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whomever performing work. Must bo owner Application # /0 t 77) 7 ( v
or licensed contractor. Address, company Hamett County Central Permitting
name & plume must match Information on PO fax 65 LI91ngt00, NC 2754e
censu.
010 587 Fax 91D-093 -2793 www.hamerl.orglpermlb
AnnlJp tion for Reeidentlal Buildina and Trades Permit s
Owners Name: , _Qt )ro, ` �..nvrm^ Date: 0412.01 l n
Site Address: 5n Q 5 R Q W I ° a �3• Phone: - 5 57 - 11
Directions to job site from Lillington: 540(1 f5Cphn Os NG en 6 Y &in *owcita E
i e t .Turn L nn+o w Qn - tin f3 N tnel �ya /us -4o .
"Toth zelsco 9\rA, 41(c, Q3',+,rph 'a- E eilr pro per+.]
Subdivision: Lot:
p1 VIera+ .p QAa ceJ + #B` o s:
Description of Proposed Work: 1�E Of o
Heated SF Unheated SF Finished Roc Room? Crawl Space ( ) Slab ( )
General Contractor Information
Building Contractors Company Name Telephone
Address License #
Must sign & fill oUt second page
Signature of Owner /ContractorlOfficer(s) of Corporation
)electrical Permit Information
Description of Work lko prc•
ret4 .. Service Size: J �Amps TPole: yes/no
QW\ ,mr# (l)& orrar, inn 4114 111.3 (c(ol5
Electrical Contractor's Company Name Telephone o � �� SP
10 (P $ra D - — CA t'f+
Address sr License #
Signature • Officer(s) of Corporation
J4l /HVAC Permit Information
C f fl
Description of Work f'O %ten , ROD Lc ( a (1 te U_ o(kL
mc'r k1 11TncAe, -]S1� %eh- 1oL5co
Mechanital Contractor's Company Name Telephone
al. C. ter ► Z7 a Z )1Z 143
Address "h r- License
Signature of u tcer(s) of Corporation
Plumbing Permit Information
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Insulation Permit Information
Insulation Contractor's Company Name & Address Telephone
8/21/U8
FROM :COMFORT WIZARDS HTG /AIR FAX NO. :9196623050 Apr. 20 2010 03:21PM P3/3
Homeowners Applying t B Their Own Home t J
Please answer me foliowing questions than see a Permit Technician to determine If you qualify for permit under nets 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 will be constructed? yes no
2. Have you hired or intend to hire an individual to superintend and manage con Sction of then
project?
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 con work to be
done?
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 dray 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 - 8 Months to 2 years permit re -issue fee is 5150.00. After 2 years re-issue fee
is as per cu t n gl ee schedule.
Signature of • er /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 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.
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 e: 0-041S4304 k0?,ral3 c
Sign wrritle: � D ate:_ `Z (htl 1 Cl
•
8/21/09