BUILDING • Each section below lo be filled out by Appliculiuu If ! 0 ` �O l / i�
whonmver performing wank. Must be owrwr
or licensed contractor. Address, company
name 8 plione niusl march Inlonnallon on I larnel( County Central Perm itting
license. PO Box 65 Llllinylon, NC 27546
910- 893 -7525 Fax 910. 893 -2793 www.harnetLOry/penniis -
Applicalfon for Residential Building and Trades Permit
Owner's Narne: &mil deates dote Dale: 7- / -/0
Site Address: X 73 Sea,/ /0 briny k OP i VC. Plione: /1) <5S3-32 list
Directions to job site from Lillin Ion: 40/ ,, es", t, CAzot k s
t a l i c m_ R! i t n t ifoi 0 0 g y a l 1 4 !"rOO& 4. f n.
Subdivision: ,Sjto y,a_ Lot: 37
Description of Proposed Work: . 7` li'o,t ar .ft / a -.7 z e. /Bedrooms: 3
Healed SF 350 Unheated SF 606 Finished Rec Room? iti/ f+, Crawl Space 4 Slab ( )
r General Contractor Information
Gon r goint, s e. NI?) 5,5 - 3 -?`142
Building Contractor's Company Name Telephone
P,O, (30 X 36 ( Cla1fa -t Ne �75� r; 33 / Efe • Address, License 11
.4a Must sign & fill out second page
Signature of Owner /Conlraclol43fha(%) of Corporation
pp E ectrical Permit hllornlalfon
Description of Work lloufl Lr d ry, ervice Size: bo 0 Amps ] Puledyno .
SC/ aliner$,oA/ S /ee•YrCC_ C "e°77 s -6
Electrical Contractor's Company Name �Telephone
/
705 /Maifr iyin fV• /I iTer f:% li
Vie f3'�r'Sf�F1�
/2:1 r2 72.42.... •
ry •
License 11
a lure of 011icer(s :1 Corpor ; CI
p Mechanical /IiVAC Penult Information
Description of Work / &24j1 /.1 t'- /%'wr oett of / /f/AC -7 a ire- U .r
r .4rencen L71"a/ 0- Air 1 q7 -o6O6
Mechanical Contractor's Company Name Telephone
3/ 13 S/],�. oa.54 Pr own n,er ?7J2 /f�6 4
A rdr Is / �r/)) License l
Signature of Olfices7 u rporal /
pD Plumbing Permit Information /b
Description of Work eat in. 'V - 7n:“. a4,7"
Jy.�, // Dallis 2
MOP • /U,. •1 /7^1x31/- �36,Z�
Plumb g Contractor's Col parr // y Name . ` . Telephn
oe
105 Meta pr (_lo. 1 r!a n / !Y ` --??51.7 cs / -?1-•-? /
b
Addre License it
0 6
Signature or 011icer(s) of Corporation
_ //
Insulation � Permiitt Information p
T21�4in -- 45 1 6 6 /avt,. -. 5 /7 64 - yCs s/ore i�G7lrnt0- ol r� /_CJpg9
Insulation Contractor's Company Name & Address / Telephone
•
Page 1 of 2 3/08
Application #
•
Homeowners Applying to Build Their Own Home
Please answer the following questions Men see a Permit Technician to deterrnine it you quality 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 perrnit?
yes _ no
I hereby certify that 1 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 any 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)) changes.
// -i ,�, 7-1 -10
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 /t 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.
Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance
cover g themselves.
Has no more than two (2) employees and no subcontractors.
While working on the project for which this perrnit 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: ( .OsK4d icire..e Lit
Sign w/Title: i/ 6 e erab' 9etDate: 7 / — /D
Page 2 of 2 3/08 •