BUILDING *Each section below to be filled out by t -500a '' 11,,``
whomever per work. Must be powner Application # t 0 ` O i
or licensed cankadar. Address, company Harnett ou
tt Cn Central Pittin
name 6 phone must match information on ty erm g
license. PO Box 66 IJlfngtan, NC 27518
910-693-7525 Fax 910. 893 -2793 www.hamettorg/permita
Application for Residential Building and Trades Permit 1 1
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Owner's Name: Vio[ Shire r4-✓1 Date: {s 4 - - 10
ret Site Address: 14 r7-. -W t A 0 (I11e"1ho hone: 1 .-t c< 1 — O F)
Directions to job site from Ullington:
C at` l . o Ak.a.0 )
Subdivision: T 0tUe_'S'T Lot: t s ib 3
Description of Proposed Work: tC51('t.Q Eli tJ #Bedrooms: `�
Heated SF 0.00 Unheated SF 565 Finished Rec Room? fllo i Crawl Space () Slab (
General Contractor Infonnatldn '
(1 at4nles.S L&nd ))eve foprne, 4- 4R1 - 0 503
Building Contractor's Company Name Telephone
6 ci a_ - f'a ; 4c- - ! . A 305 37485
Address License #
Must sign & tilfout second page
Signature of Owner/ Contractor / Officer(s) of Corporation
EI ct eal a It o atlo
Description of Work ctzsv Service Size: /Imps TPole3 ( Sit /no
- 4 &(erine v Fi31 = I3
Electrical Contractor's Company Name Telephone � � Q �/
A 1 all �tA r7 . IS. - L 9
• .. oCOb i O' � Address Cleanse #
Signature of Officer(s) of Corporation
)NechanIcal/HVAC Permit Information
Description of Work 1-hl A C
0 friar oo - gg -6311
Mechanical Contractor's Company Name Telephone
1910 -B Prurale>zb- el 5PLC. aR,Pb? a957P111 -3
Address License #
Signature of fficer(s) of Corporation
Plumbing Permit Informatfoq �� �
D scriptlon of Wo !tun hi # Baths
PA Nei' Vktm Mien •e (oA- 04,59
Plumbing Contractor's Company Nang Telephone .
"Po. 861 - 7mmo COOLS' &IC 475a1 3 /fob
Addr ss • License #
lgnature of Officer(s) of Corporation
Insulation Permit Information
Qcmkierlaind l ac IA 0-i 'm . 46 g
Insulation Contractor's Company Name & Address Telephone n I
L_) oz.nse " l
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Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technldan 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 will be constructed? — yes _ no
2. Have you hired or intend to hire an individual to superintend:and manage construction of the
project? • _ yes _ no
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 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 do you understand that ii 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 Is correct
and that the construction will conform to the regulations In the Building, •Elecbicai, Piru_nbing_ and _
Mechanical codes, and the Hamett County Zoning prdinance: !Mate the informatio on the above
contractors Is correct as known to me and if an 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 $150.00. After 2 years re -issue fee
Is as per current fee schedule.
�� (e U — 10
Signature tureoOwner /Con r /Officer(s) of Corporation • Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
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x 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
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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.
1• 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. h, a n
Company or Name: &U)IV1PSC /And �i�C' AlPIpmC .
Sign wftle: �� �� '
( Date: l.0 " ��
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