BUILDING Application # /0 �� Z
• Each section below to be filled out Hamett County Central Permittin g
Must be owner oorrrlolcenaed PO Box 85 L IIlington, NC 27548
contractor. Address, company 910-893-7525 Fax 910-893-2793 www.hame8.org/permits
name& plane must match
//,,// Application for Residential Buildina and Trades Permit
Owner's Name: !/(/yin tin e�r...dew Date: /9 /10
Site Address: 764 6/714,4a PR n Phone: 9/g- s39 -jo7 7
Directions to job site from Lillington: %Tien K/ nev oz, 7 finhS on .Eye -/
Subdivision: 7, e.. pr Lot: / /3
Description of Proppsed Work: /Pt* gwr # of Bedroom • 3
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: lab: [/ kf/. //.
��J /f / General Contractor Information
/Ilan 1. .a..r� 7` r 9/L5:7 K-/ 3'17
Building Contractor's Company Name Telephone
Add as Email Address
Signature of Owner /Contractor /Officer(s) of Corporation Manse #
glectrlcal Contractor Informatlo /
Description of Work /Uf/F1 liismp. Service Size: Amps T -Pole: // No
.Q. ■cAsn. aLr r : r . v9 'na /.?S'/
Electrical Contracto s Comps Name Telephone
co/G/ A » . 4,,,C. 87504, Addr 1 Email / ss
,� 1, dt/ / ti
Si ne re • J /1 er /Contractor /Officer(s) of Corporation License #
MechanlcallHVAC Contractor Information
Description of Work frost) /aton►d:.
Sit .�4 o otsc*e 9A 3,2f n.
Mechanical Contract Com any Name Telephone
393 Sput a 43C fl/. l. 9
Address Email Address
Ca �� /e nse #
gna of Own /Contractor/Officer(s) of Corporation License #
plumbina Contractor Information
De of Work,�2s►.t/ /4eIG # Baths
/ S J CrJvpli / on
Plumbing Contractor's Comp ame Telephone
Adde- Email Address
4 .-,- _A `, a tm-a-
i • natur 7' Owner /Contractor /Officer(s) of Corporation License #
. // ./' /� ' ��--��y7
Insulation Conntraacttor Q . / ,p,'e
:140/ ... So• i gne .1// 0 7 /0G ;SI'f/7t r�',wtr 7 /7 �} -IOC' x779
Insulation Contractor's Company Name & Morass �C � 7�jS Telephone
`NOTE: General Contractor must fill out and sign the second page of this application.
: r i rFY " a d•6rq i p1rr1:ry01 - - ;I 2
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technidan 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
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 acti es? _ Yes _ No
4. Do you intend to schedule, contract, or directly pay • - I phases of
construction work to be done? _ Yes , _ No
5. Do you intend to personally occupy the t'i ding for at least 12'consecutive -
months following completion of cons r ion and do you understand that if
you do not 'cln so, it creates the • - sumption under law that you fraudulently
secured the permit? Yes — No •
I hereby certify ; t l have the authority to'make necessary application, that the application;is correct
and that the constructionwill.confonn 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 site plan,
number of bedrooms, building and trade plans, Environmental Health permit changes or proposed use
changes, 1 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 e per �current e c dule.
p
Signature of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation.N.C.G.S. 87 -14
The undersi pplicant 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) 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.
aC�H s one (1) or mom 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. ,, 9 /J
•
Company or Name: l/"V ^^ £ irSiPac4ar
Sign Willie: i S !>I Date: 6.A
�,e;id =nUal Fs tpq . li:)IiCali.in L •;1 2 7:11 :;