BUILDING tiEadtatwronb�kuto Mdesout br
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no mo a pram mat m�tdi waamtmn on Hemelt Cowtty Central PamHUig
//6993-7626 Fa 910-010-2793 ww .h hnnNt.naipotmy
�ff // Na nd& Bulldtna end Trades Pfaff: nn an
Owner's Name: [ I Ae lt —2 BSc Date: i I I
Site Address: I g CO I! - . . : v e• II / ph one: Gl l s - : - 35 1 � 3 //�
Directions to jo • • i . from Lin ngton, ' LI 21 ' • i t S / •Y73�
T_.. a @ S i • only mC} • «f , 1 (.e -iS
o n-ta i osc (. Pt °" • 4? , - ,70 4 On/ VS / 'le-- r Cow r
Subdivision: Lot l ` '
Description of Proposed Work: #Bedrooms:
Heated SF Unheated SF Finished Rec Room? Crawl Space () Slab ( )
General Contractor Infonnatlop
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Building Contractor's Company Name Telephone .
0 w K.■e,ti
7 ewZH��` C-/ License I
Mud sign `IA out second me
1ptaturs al Onned/anbector/O3s(s) of Corpondbn
Descrpdon of %bran Fp U , enk a S �� ,o ps TPole: yes/no
WSW') P, .P Iigo I Gild m --S°(79)
Elegy Contractor's Company Name Telephone
Ad license d
Signature of Of cer($ of Corporation
MlibIlliagetagamtafgungo
Desalpton of wok
Mechanical Contractor's Company Name Telephone
Address License t!
Sigma,, of onto na) of Corporation
alMMILEUMILItgagga
Oesafplion of wale If Baths
Plumbing Ccn roc&. Company Name Telephone
Address License ry
Signature of O cans) of Corporation
lnsuladon Permit information
insulation Contractor's Company Name & Address Telephone
8, 21.08
Homeowners Applying to Build Their Own Home
Ple a ante tie orbs, guidons Nun go a Pre nd.rJ.n b aunt N ru quay far pre is Ono
Questionnaire per Q.S. 87 -14 Regulations as to Issue of Building Permid (Memo newt upon nequsa)
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
p _ yes _ no
3. Do you intend to directly control & supervise constriction activities? yes _ no
4. Do you Intend to schedule, contract, or directly pay for all phases of constriction work to be
done? _ yes _ no
S. Do you intend to personally occupy the building for at (east 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 herald ait)y tlst I have the authority lo mstw necessary apptcedoy that the appends' 1 canned
and ttrf is corMbuctlan coq creamy to is regulseors in the Solving Electric* Pkanbbtg and
Mend* l codas, and the Hemet Canty Zankq Ordnance 1 stets the khlbnnstion on the above
contredtci` is correct as known to ns and N dhrSig uu occur Inckdrhg listed contredofs, tie pr,
minter of bedrooms, bulking end bade plans, nVsrhmsrhdtl Hssth permit lunges or proposed use
changes, I codify it Is my rseponelbltly to notify the Harnett County Centre Paneling Deport nest of
any and a changes.
EXPIRED PERM? FEU - 8 Months to 2 years permit re-issue fee is $180.00. Alter 2 years re -Issue fee
Is as y p pe er current Ile schedule.
s9 ( 0,.7� (� - a9 —/ D
n
si c�OmNHContrada afire fp of Corporation Date
Affidavit for Worker's Compensation N.C.O.s. 87 - 14
The rnderdp ed epplIcent enw
Gwen Contractor Omer O81csdAgent of the Contractor or Owner
Do hereby confirm undo penalties time is pe soap), Omits or corporation(s) performing is work
at t In is permit
(- three (3)o more employees and has SAWS workers' compensation Insurance to cover them,
� Ho one (1) or more sabactrectors(e) and has obtained waken' commoner' insurance 10 cover
then.
Hes one (1) or more uuboontradon(,) who hes thetr own polcy of wafters' compsnsallon Insurance
covering Mowing
_
Has no mom tun Iwo (2) employees end no suboonbadore.
totes working on the prided for Mild' this pommtl is sought it Is understood that is Central Pending
Department Issuing is permit may require certificates of coverage of worker's compensation Manna prior
to issuance of the pen. and at any tine during the permitted work from any person, firm r corporation
carrying out the work.
Com or N ! f
Sir w - �� ��uo2T (J Dor la - 2-1-1 p
8/21/08