BUILDING ' Each section below to be filled out by
whomever performing work. Must be owner Application # /0- ,$ .2 14 s 7
or licensed contractor. Address, company --
name & phone must match information on Harnett County Central Permitting
license. PO Box 65 Lillinglon, NC 27546
Phone 910 -893 -7525 Fax 910 - 893 -2793 www.harnett.org
Application for Residential Building and Trades Permit
Owner's Name: 6,4), - Q s i'I t 2-n, Date: C -01- /Cs
Site Address: r & P btaa r 4- Phone: q11-4.39--V71
Directions to job site from Lillington: 1 o y ,,, x).5 1,,..,.. )1 F,
Subdivision: P4+4.3 ®n;nl Fpm,_
Lot: /
Description of Proposed Work: it/ ei u . S F
#Bedrooms: 2
Heated SF /046 Unheated SF 31 Finished Rec Room?
N
General Contractor Information Crawl Space (� Slab ( )
Bradley Built, Inc. 919 -639 -2073
Building Contractor's Company Name Telephone
Ad46 , Stencil Rd, •g NC 27501
54519
License #
�/��� Must sign & fill out second pa
Si. ' ure of O 1r er /Contractor /Officer(s) of Corporation
Electrical Permit InformaQQon
Description of Work New Residential Service Size: LO0 Amps TPole ye no
Stanrit -Owen Electrical, Inc. 919- 639 -2073
Electrical Contractor's Company Name Telephone
466 Stencil Rd., ng• ,NC 27501 13075 -L
A
License #
s igma ure o ticer(s) of Corporation
Mechanical Permit Information
Description of Work Residential
JC's eating 6. Air 919- 552 -6258
Mec .nic.. Contractor's Company Name
Telephone
153• Wade .ephenson f., Holly Springs, NC 12655 -E13
Ad ri ress
Ii
a License #
Si. atur!of *Ili tr(s) o Corporation
Plumbing Permit Information
Ile ^lotion of Work Paciripnl- al 2
# Baths „c
8ernes Piumbincr Inc 919- 639 -0935
Plumbing Contractors Company Name
Telephone
PO Box 1207, Angier, NC 27501 P17735
et ,,-e.�� License #
Signature of fficer(s) of Corporation
insulation
Insulating, Inc. , 1212 Home C t
. , Raleigh, NC 27603
Insulation Contractor's Company Name & Address 919 - 772 -9000
Telephone
Page 1 of 2
9/07
Application # !o- S`oo its 3 f 9
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician 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 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 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 ?�y 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
��,j
Signature of Ow rlContractor /Officer(s) of Corporation Date � �°
l
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), firm(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 thatthe 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 orNa• - . Br.d ,/y ��ilt, Inc.
i �
Sign w /Title: � � L AI `fl res ident D e: C. 2 - /0
Page 2 of 2 9/07