BUILDING •
Each section below to be titled out by /D 5 a 221 / D0
whomever performing work. Must be owner Applicatiuna Y / fi n
or licensed contractor. Address, company
name 8 phone must match information on Harnett County Central Permitting
license. PO Sox 85 Lillington, NC 27506
910- 893 -7525 Fax 910. 893 -2793 r www hamett.o
1 ion for Resident a B 11 9 persRa
Owner's Name: - Ts des rmit
,. � ,', Date: •
Site Address: , _ i,.
Directions to job site from Lillington: � Phone: 9!S_,s '2")
-- -� .t e &Ats a.4 s s Le
•
Subdivision:
-
Description of Proposed Work: • t� LOt' S
Heated SF #Bedrooms: 3
Unheated SF Finished Re; Room?
t3eneral Contrac•�• t -• -- -•- Crawl Space ( lab (
Building Contractor's Company Name ` eph
2- - Telephone
Addre9�� 3-L.; YGY9.f
License #
�
•r%re of Owner /Contractor / cer(s) of Corporation Must sign 8 fill out second page
Description of Work W , E �rcal Permit Informati
Des Tobn Service Size: Amps TPole: o
C/. �t 2(`1 7f0 /
. Electrical Contractors Company Name
24 Telephone
Address - � a((yy
dfw License #
S i gi Satu v of Officer(s) of Corporation
Mechanical /H , Permit info.- nar•nn
•
Description of Work t / fits (Ra
S f'dJlo.. /� w /• I
Mechanical Contrd s Company Name 9/ % 9Z9 O6yG
S - Telephone
Address , i �
License #
Signatu of criecorporation
Plumbing Penis Info
Description of Work Mis�S - """°`"x
L+a, W L.. Baths
Piumb ng Contra l cttor s Com
pant' Name 9.fi (�sY G yr
31 t'ia nl /a ( p' ' Telephone
Address G7 7S3 s/
/ice .�,r; License #
Signal fee pr Of ficers) o f Corporation
lulation Perm) Informersnn
1 ulation Co tractor's Company Name 8 Add ess c S
Telephone - 641:41, 99
BUILDING
Paget 2
A I / 4/08
Homeowners Applying to Build Their Own Home
Please answer the fallowing questions then see a Penult Technician to determine if you qualify for penult under Owners ptio
Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo availabl= Ton request)
I
1. Do you own the land on which this building will be constructed? _ yes _ no
i
2. Have you hired or intend to hire an individual to superintend and • : age construction of the •
project? -, „ = yes _ no
3. Do you intend to directly control & supervi a nstwction activities? - yea _ no
4. Do you intend to schedule, co • : ct, or directly pay for all p . -es of constriction work to be
done? yes I _ no,
5. Do • ' : d to personally occupy the building for at least 12 consecutive 1 = • s following
. etion of construction and do you understand that if you do not do so, it creates t .
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 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 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 cu a hedule. pp •
tl.'� tit {
Signature of ner /Contractor/Offlcer(s) of Corporation i C!
Affidavit for Worker's Compensation N.C.G.S. 87 -1
Th undersigned applicant being th e:.
General Contractor Owner Officer /Agent of the Contractoi or Owner
Do hereby confirm under penalties of perjury that the person(s), flrm(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' comp nsati 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 compens 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: ,.///in 17.+S /r"sCiO_-.1/4_ I
Sign w / /- ate: : � /r/,/, Ttie: ���0�� - .Sc.�.•..a�a.e4.� �= _ -���
8/21/08