TRADE M.
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a.censed contractor. Arias. corners Application s
none s pray rant nod l�am.lbn an Hannah County Central Permitting r
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Owners Name: / 44 A A Date:
Site Address: Phone:
Directions to Job Ste from Lillirgton:
Subdivision: Lot
Description of Proposed INbrk:
//Bedrooms:
Heated SF Unheated SF Finished Rec Room? Crawl Space () Slab ( )
Building Contractors Company Name Telephone
Address
Lioanse •
sign •
Signature of Owner/ContractodOgkxr(s) of Corporation Must 8 out second paps
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Service Sias
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Electrical Contractors Company N
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Address •
275 License
of Of r(s) of Corporation
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Plumbing Contractors Company Name T el S /
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8'33 y '
A 2 License
Sign d Merle) of Corporation
Inagustemunt
Insulation Contractor's Company Name & Address
Telephone
8121/08
Homeowners Applying to Build Their Own Home
Please answer the Mosey Men see a Perms Taduddan b d4..,. a Wyou q for puma UMW Owners Emh>p&..
Questionnaire per G.S. 87 -14 Regulations as to Issue of Bung Permits (Memo available upon request)
1. Do you own die land on which this building will be constructed? _ yes _ no
2. Have you • or intend to hire an individual to : I • • : and manage construction of the
PfOIect? yes _ no
3. Do you intend to dsecfy corbel : • construction activites? _ yes _ no
4. Do you intend to schedule, 1 or directly pay • - II phases of construction work to be
done? yes no
5. Do you Intend 1 occupy the building for at lead 12 consecutive months following
completion of • , ••• I. • n and do you understand that if you do not do so, it creates the
presu • 4.;41. that you fraudulently secured the permit?
—!es _no
I hereby certify that 1 have the authority to make necessary apps that dm application is correct
and that the construction will Caton to the regulations in the Bunting, Bedded, Ong and
Mechanical codes, and the Hamel County Zoning Ordhrence. 1 state the information on the above
contractors is coact as known to me and if arm changes coax inducting fisted contractors, site plan,
number of bedrooms, budding and trade plans, Envbormtentai Health permit changes or proposed use
changes, I certify it is my responsibility to notify the Hamel County Central Permitting Deparbnent of
any and an changes.
EXPIRED PERMIT FEES - 6 Months to 2 years permit re -issue fee is S150.00. After 2 years re-issue fee
is as per anent fee schedule.
77 fad C /79/�o
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Signature tr OwnadCa cer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
X General Contractor x Owner X 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 two obtained workers' compensation insurance to cover
them.
X Has one (1) or mom subcontmdors(s) who has their own policy of workers' compensation insurance
covering themselves.
_ Has no more than two (2) employees and no subcontractors.
While worldng on the project for which ids permit is sought it is understood that the Central Permitting
Deparhnent 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, fan or corporation
carrying out Me work /� � , o e. �� ,
Company or Name: ace- 6rc,2 . (ixa. ...t . 4
Sign vv/Title: le: � )Of,,,- 21444.4.s., Date:
j/ 8/21!08