BUILDING Application # ! ' fd1 L / 55C
*Each section below must be filled out by Hamett County Central Permitting
whoever is performing the work. Must be y g
owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546
company name & phone must match 910- 893 -7525 Fax 910- 893 -2793 www. harnett.org /permits
information on state license. COMMERCIAL
Aapllcatlon for Building and Trades Permit
Owner's Name: 0 i- Si.I P; L Date: S 27 - l 0
Site Address: /04 K)-mOri IIA- Lan `v&urA / 23332- Phone:
Directions to job site from Lillington: This- ( -I -f 2 7 /...) #0 ISM.- 4ff..10 (Atka ✓1rJ
I o l(Lc./ 6t,. r `1 - L..(0 La 4-e !K. )1-, 14,....,),;11 Lk, 'Too Or nig- 1,
Subdivision: & k IC Lc_ke kLit.,eSS PA ✓ Lot: `7
Description of Proposed Work: `x4 S ICcs -k ..- Ft
Heated SF 240 Unheated SF
General Contractor Information: Building Cost $ 1- UV, 60
&€ .cJ t e 8,,,,.11- Z"„ t.. owl Le 3L5 20'13
Building Contractor's Company Name Telephone
(Ith 54.r.0 I Rd tic A/L 77;OI 1 W el( ew1(0 �1� I.Co�
ss � ‘e%'4- , Email Address IC/
1Vx. . i 54
Signature of Owner/Contractor/Officer(s) of Corporation License #
JE ec ric I Contractor Information: E lectrical Cost $ Y 0,OUo
Description of Work 14dd eXcYf4 5 Size: Wet) Amps #T -Poles UP
S L a- t- - c.U.v'tn [ €c 4 r,t- '1I (23 20`73
Electrical Contractor's Company Name Telephone
/S (0 s4 -a,,..LI as Ain 't.,- ,
. ilk- 7 s i
• ss `r Email Address
` • aL r♦, _y 1. ) 3o15 - L
Signature of Owner/Contractor /Officer(s) of Corporation License #
Mechanical Contractor Information: Mechanical Cost $ /O AJD
Description of Work 1&e IA) pr k (full( Fur 11cs «,-,, i # Units
P-e $Zg - 512
Mechanical Contractor's Company Name Telephone
:5 11 1o,iia, b 1 A...k t, 2 .. t.) la
Addr� // ' Email Address
> e t ure of Own /Con ractor /O cer(s) of Corporation License #
r Plumbing Contractor Information: Plumbing Cost $ 2-5 nu°
Descri tion of Work Rewur k UT 2. 10“ 1 k, f� 1,.1,..: 2
1,,,, , # Baths hey PIt.,,t,,b;, - n .
Plu japing Co ractor's Company Name Telephone
(r•0- _e I d k It )'in1,tl 21cCv1
Ad ess Epqail Address _
r ,.(.., ...- -/ y I �l 135
Ignature of fDwner /Contractor /Officer(s) of Corporation License #
UUU Insulation Contractor Information
Insulation Contractor's Company Name & Address Telephone
`NOTE: General Contractor must fill out and sign the second page of this application
C.)rnnerciel Building Application 1 or 3/10
Sprinkler Contractor Information
Sprinkler Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Fire Alarm Contractor Information
Fire Alarm Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Driveway Access - NC Department of Transportation Driveway Access/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 my 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 - 6 months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
i rged at full price pe rrent fee schedule.
yr f 5- d7- is
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 perjury that the person(s), firm(s) or corporations) 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 Nam: B L t 'i4 1 1
Signwlfitle: _ Date:
•
Corrmiercial Butlding AppI'ca? on 2 of 2 3'10