BUILDING ' Each section below to be filled out by
Application fr 1(1 - R nti q
whomever performing work. Must be owner
or licensed contractor. Address, company
name 8 phone must match information on Harnett County Central Permitting
license PO Box 65 Lillington, NC 27546
Phone 910.893 -7525 Fax 910. 893.2793 www.harneh.org
Application for Residential Building and Trades Permit
Owner's Name: Stancil Builders Inc • Date: G 7
Site Address: 7S Alyn.. C f Phone:919- 639 -2073
Directions to job site from Lillington: 4111 towards Fayetteville, Turn Right
Hwv27, turn Left on Tingen Rd. Subdivision on Left
Subdivision: Pattons Point Lot: jr?-
of Proposed Work: RPS idential Home #Bedrooms: 3
Healed SF i / y.,g Unheated SF 6,o9 Finished Rec Room? N Crawl Space ( ( )
General Contractor Information
gtanch Atti idrrn. Tnm 414- 61q -2071
Building Contractor's Company Name Telephone
_I 466 S x n '1 Rd., An•ier, NC 27501 034533
• d —/�� License #
`� / ��t= must sign & fill out second page
gnature of Owner o 'IFS for /OI er(s) of Corporation
Electrical Permit Information
Description of Work New Rest dPnt i a1 Service Size: 200 Amps TPole: Gpo
Stanch -Owen Electrical, Inc. 919- 639 -2073
Electrical Contractor's Company Name Telephone
':..at R.. , • n•ie / NC 27501 13075 -L
• n. re License #
Sig,„Iof Olfic:'s) of Corporation
Mechanical Permit Information
Description of Work Residential
JC's Heating & Air 919- 552 -6258
Mechanical Contractor's Company Name Telephone
15:• Wade Stephenson I.,�olly Springs,NC' 12655 -H3
Add •,
de
License #
Signaure .f Offic t s) •IFF:rporation
Plumbing Permit Information
Description of Work Residential #Baths
Barnes Plumbing, Inc. 919- 639 -0935
Plumbing Contractor's Company Name Telephone
PO Box 1207, Angier, NC 27501 P17735
Address
\ License #
Signature of Ificer(s) of Corporation
Insulation Permit Information
Insulating, Inc.•1212 Hnme Ct.,Rateigh,NC 919- 772 -9000
Insulation Contractor's Company Name & Address
27603 Telephone
Page 1 of 2 9 /07
Application # ! 0-3 - 66 a 431 y
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you qualify for ipermIt 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 if you do not do so, It creates the
presumption under law that you fraudulently secured the permit?
yes no
I hereby certify that 1 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,
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.
4. 7/6
Sig ature of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
X General Contractor Owner Officer /Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), tirm(s) or corporation(s) performing the work
set forth in the permit:
X 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.
X 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 at 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.
Comp. ••or Nam r: , `a anc s, I, ..
Sign ., +' e: Lit � / /I / Pres ider[jete: 21• Id
Page 2 of 2 9/07