BUILDING Each section below to be filled out Application #10 S00 - Z y,3 3 7
by whomever performing work. Harnett County Central Permitting
Must be owner or licensed PO Box 65 Lillington, NC 27548
contractor. Address, company 910 -893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
name & phone must match
Application for Residential Building and Trades Permit
Owner's Name: Wynn Construction, Inc. KAY Date: 0 71 2(2 1/0
Site Address: / 8 S Letchner Ln. Lillington, NC Phone: 919 528- 1347ext.107
Directions to job site from Lillington: 421 toward Sanford,
Left on Old US 421, Left on McDougald, Right on Adcock Lee/ ow kie , Atet
Subdivision: Pioneer Farms ‘ SGIO'zys 8 Lot: /0
Description of Proposed Work: New Construction Single Family Residential # of Bedrooms: 3
Heated SF: 1 Unheated SF: 11 Finished Bonus Room? No Crawl Space: ✓ Slab: _
General Contractor Information
Wynn Construction, Inc. 919 528 - 1347 ext 107
Building Contractor's Company Name Telephone
2550 Capitol Dr. Creedmoor, NC 27522 edward@wynnconstruct.com
A ihrei 2i�iLC.N/ Email Address
46295
nature of Owner/Contractor/Officer(s) of Corporation License #
Electrical Contractor Information
Description of Work New Construction Service Size: 200 Amps T -Pole: ✓ Yes No
R. A. Jackson 919 730 - 1251
Electrical Contractor's Company Name Telephone
9261 Raleigh Road Benson NC 27504 rajacksonelectric @att.net
Ala Email Address
!P 1 "pT� ' 21144
Signat re of Owner/Contractor/Officer(s) of Corporation License #
Mechanical /HVAC Contractor Information
Description of Work New Construction
Stephenson HVAC 919 329 - 0686
Mechanical Contractor's Company Name Telephone
343 Shipwash Drive Garner, NC 27529 stephensonshvac @aol.com
fildcess Email Address joic 18644
Slgna9 re of O her /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Construction # Baths
Thorton's Plumbing 919 669 - 8655
Plumbing Contractor's Company Name Telephone
3160 - A Omsar Rd. Clayton, NC thorntonsplumbing @embargmail.co
Address Email Address
22152
Signat a of Owner /Contractor /Officer(s) of Corporation License #
Insulation Contractor Information
Tatum Insulation 919 661
Insulation Contractor's Company Name & Address Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Residential Building Application 1 of 2 03110
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 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 state the information on the above
contractors is correct as known to me and if as 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 all changes.
EXPIRED PERMIT FEES - 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is as per current fee schedule.
� �lD (i,.,.�t. ?- 2 0 - Ia
nature of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
1 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.
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
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.
Company or Name: _ 1. Wynn Construction, Inc. C Sign w/Title: K ti t C el 0 Date: 7 /Za / 2010
Residential Building Applicalion 2 of 2 03/10