BUILDING * Each section below to be filled out by Application # 1.2 5-c7 2 / 1/. 0
whomever performing work. Must be owner
or licensed contractor. Address, company
name & phone must match information on Harnett County Central Permitting
license. PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
Application for Residential Building and Trades Permit
Owner's Name: J e r e rt y F y t Date: 6 - -z �' "? 0/0
Site Address: 18 31 W h ! e fifer' r Phone: get — 3 5 - 3 Sa
Directions to job site from Lillington: NG a/ 'ta Jcri NQ.rr+3 ` ur1/ L eff
id e d K `'II- "d fa to t o `e r air
Subdivision: Lot:
Description of Proposed Work: —20 X 2 O + /5 a /ice #Bedrooms:
Heated SF Unheated SF Finished Rec Room? � Crawl Space () Slab ( )
G f e General Contractor Information
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Building Contractor's Com any Name Telephone
/00 8 &i//e" fry 4/7`' / .✓/i�
Address License #
ru y tic v V4 /' + nice NC a 7 ilkP Must sign & fill out second page
Signature of ner /Contractor / Officer(s) of Corporation
Electrical Permit information
Description of Work del Y- (nit hi Service Size: Amps TPole: yes /no
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Electrical Contractor's Company Name Telephone
`7/<30 -/ F+ 12 spray 4 i / / / — L
Address License #
�j
C ('9Sfe 6 dcrat
Signature of Officer r ion
Mechanical Permit Information
Description of Work
Mechanical Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Plumbing Permit Information
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Insulation Permit Information
Insulation Contractor's Company Name & Address Telephone
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Application #
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 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 my changes occur including listed contractors, site plan,
number of bedrooms, building and trade plans, Environmental Health permit changes or proposed use
changes, 1 certify it is my responsibility to notify the Harnett County Central Perm itting Department of
any and all changes. J
• / i / r / aO l
.nature of Owner /C• - or /•ff cer(s) of Corporation )(ate .
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The
1 undersigned applicant being the:
/General 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:
Has three (3) or more employees and has obtained workers' compensation insurance to cover them.
V Has one (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover
\ V 7 them.
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 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. //rid
/ Company or Name: O rd q G 4r¢ _ '9 Rot/445 / Sign w/Title: a'WNer L Date: G ?/ o�0 /O
/
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