BUILDING Each section below to be filled out Application # ! 9 00 z45 ! 5 ( 5
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by whomever performing work Harnett County Central Permitting
Must be owner or Ilcensed PO Box 65 LIIlinglon, NC 27548
contractor. Address, company 910 -893 -7525 Fax 910- 893 -2793 www. hamett.orglpennIts
name 8 phone must match
//,,,, Application for Residential Bulldina and Trades Permit
Owner's Name: i43#vn .•.c74D.� - / Date: G/ a
Site Address: .� 72 aD //( r T £ pa. Phone: 9 9- .n9'-009
Directions to job site from Lillington: %wrn ie 44 t#9 -2°45 On iept
Subdivision: 7 i en r. Lot: 9' 7
Description of Pro Work: /kW 4Ar # of Bedrooms: 3 C/
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: lab: Gr/ 4( / � General Contractor Information
la ywn l.e+nS/r / 74s 9/9 S°7 K- /3'/
Building Contractor's Company Name Telephone
gine sale. ios eraineve4t
Addrgss , Email Address
/n9r
Signature of Owner/Contractor/Officer(s) of Corporation Li dense #
)clectrIcal Contractor Informatlo
Description of Work IVI .'N kw. Service Size: RCP Amps T -Pole: es No
£ Ar. p9.. 73U' /.2.5'/
Electrical Contracto s Compa Name ,F �.. ,/ Telephone
94241 A ; sa-, nAc. a75Dy
Addr r Email •flgress
Si na re • 7' ner /Contractor/Officer(s) of Corporation License #
MechanicallHVAC Contractor Information
Description of Work ,yea) /4ewc,
54,436 <... d4 ,'Q 9.q- Say. 01,51'
Mech nical Contracto141 Com any Telephone
393 snt,I a Gamier /MI. a 9
Address Email Address
sf X - � License #
gna of Own /Contractor /Officer(s) of Corporation License #
Plumbina Contractor Information
D� tion of Work A/ Male # Baths 3
�l�fsPA' .5 P �/ , ..•. oir g r 9/9- 4,576 — l eg 33
Plumbing Contractor's Compa me Telephone
3/6.0 4 Oman r6 nikc, a761
Addre Email Address
J . ✓ i 2 215
1 • natu ,,! Owner/Contractor/Officer(s) of Corporation License #
� / � Insulation Contractor (Information / e
74m . /�!NN.M/oN 5-/''J o //j Svb�Sfa�,l. ��irr A -44/ ff7
Insulation Contractors Company Name 8 A / S 75-2 Telephone
'NOTE: General Contractor must 1111 out and sign the second page of this application.
P:.q:a hJ i5 ='] f i r::Viptl pf2
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Tedmidan 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? _ Y= - _ No
2. Have you hired or intend to hire an individual to superintend and ,
manageconstruction of the project? _ Yes _ No
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3. Do you intend to directly control & supervise c• • - ruction activities? _ Yes _ No
4. Do you intend to schedule, contra , • r directly pay for all phases of
construction work to be done? _ Yes _ No
5. Do you intend to • = •pally occupy the building for at least 12 consecutive
months follow in r • mpletion of construction and do you understand that if
you do not • so, it creates the presumption under law.that you fraudulently
secured a perrrtit7, ..
Yes _ No
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I hereby certify, that I have the authority to :make necessary application, that the applicationas 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 informatlori on the above
contractors is correct as known to me and if lax 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 - 6 Months to 2 years permit re-issue fee is $150.00: After years re -issue fee
is as per current fees rad
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Signature of Owner /Contractor /Of icer(s) of Corporation Da •
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undo ed 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) perforating 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.
as 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. MOM /�
Company or Name: MOM (0.0 c ��
Sign w/Titie: / • � _ %�•� Date: 6/91
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