BUILDING ' Each section below lo be lilted oul by Applicaliuu 11 /� S 24 / (p /
Mittman( perlonuiny work. Must be owner
or licensed contractor. Address, company
name 8 phone must match inlonnallon on Harnett County Central Perri
i1tir
license. PO !Box 65 LiIlinylon, NC 27546
910- 893 -7525 Fax 910- 893 -2793 www.harnell.ory /permits
Application for Residential Building and Trades Permit
Owner's Name: Co Ar7 de es l Dale: 7 —( —/o
Site Address: 235 /loon /,54.t`"prr✓e / / 4� Plione:(`Ilf) 5S3 t{a
from Lillin Ian:
Directions lo job site I LID/ , emit f' „ el �/ r. a
L List nit_ Ark,ws t 0 en iyit Nod& tiff -
Subdivision:.SiF�.e� Lot: it
Description of Proposed Work: e0»175y.in iia.r evi 3.a /t Am., Fesi Bedrouins: 3
Healed SF I` a.. Unheated SF 744 Finished Rec Room? AMA Crawl Space pikSlab ( )
General Contractor hlfornlation
Ga/14 7 n n7 - r/hran 1Ps e. NI?) 33 -3.? tE2
Building Contractor's Company Name Telephone
Address, O (3oX X36 C/o7 -t , 7S�Z e 33 / &%
License It
•46 flfio Must sign & till out second page
Signature of Owner /Contractorcilllcer(s, ) of Corporation
p E ethical Permit Information
Description of Work /loaf! :.r dtn,br,, ervice Size: ..70 0 Amps TPoleeno .
S({ntwt t oA/ £ /ee.S4-cc Ca 7S -6S 7 7
Electrical Contractor's Company Name Telephone
705 Mon (Cs i✓, it: rr /»T ' r l �r se/oft-pc Z sPsFb • .
A License 11
JI( /i L/ 11 .. ar
m _ are of Olficer(s - 11 Corpor iri
Mechanical /I Permit Information
Description of Work/7647f / 'f /r;%+t oat °, / /VAC - r - enter Pe %,.r.
Sf 4,enset, M'a/ u s-- ,4;,.- �`ft��r��z ...ci z
Mechanical Contractor's Company Name Telephone Telephone
37 (3 �SJz, ,0 7 1 1JC[S/ Yr. &orH.€ e. 2 75 /f36 4 y
A�ItJy :l /� zy /` —/
License JJ
Signature of Officer( of 9 rporation •
p Plumbing Permit Inforinalion
Description of Work /lorr /'t `Y Zr,:t- aca" 11 Baths 2
Ala r,goet f /Une-h/,+i 0 /7 ,1 r5 y ^sE,e?.2
Plumbing Contractor's Col pany Name Telephone
OS Mefcr 17r. L'l / / l e 75R 6 / .?(-7 e
Addre�$ License 11
ant OM*Go(
Signature o 011icer(s) of Corporation
oration
/ Insulation Permit Information ///
T7 wt - 45144%rt• -, S/ 64 ruq.S ?re ife/ 6Zrrn Of t( '1J7
Insulation Contractor's Company Name & Address / Telephone
•
Page 1 012 3/08
Application #i
Homeowners Applying to Build Their Own Home
Please answer the following questions Then see a Permit Technician to determine it you qualify for permit under Owners Exemption.
Questionnaire per G.S. 87 -14 Regulations as to Issue oI 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 stale 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 II changes.
/ e t /fir _ ? — / --/ O
Signature of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
General Contractor Owner Officer /Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), finn(s) or corporation(s) performing the work
set forth in the permit:
Has three (3) or rnore 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
cover ng 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.
Company or Name: ( 11 A" Esce - ,1
Sign w/Title:� ��' Ge"'e�t taat 7 / — / 0
Page 2 of 2 3/08