BUILDING • Each section below to be filled out by Application # /� ^�� 2�� DL'
whomever performing work. Must be owner
or licensed contractor. Address, company
name 8 phone must match Information on Harnett County Central Permitting
license. PO Box 65 Lillington, NC 27546
Phone 910-893 -7525 Fax 910-893-2793 www.harnett.org
( Application for Residential Building and Trades Permit
Owner's Name:ttlCIo.Okla. r.{' 100.144( La Date: 7
__ Site Address: 7 31 t'o.to t twi Data- C: rrit Phone(9ID) i i)-6 - r).%9g
Directions to job site from LIIIIngton:
West on E Front St toward 1 St. Tum left onto 1" St Tum right on E. Lofton St
Tum left on S. Main St US- 401/NC- 210/NC -27. Continue to follow US-401. —
Tum right onto Elliot Bridge Rd. Tum right on Will Lucas Rd. Subdivision is on right
Subdivision: COanl( 'NO. Oc.kS Lot: 52-
Description of Proposed Work: S i vie - 14).4.1.1. ) > wc)ling #Bedrooms: 3
Heated SF /Sob Unheated SF 670 Flnishe3 Rec Room? O yt�L.. Crawl Space () Slab,}
1 General Contractor Information
1;;11 Ora klyra,..,froflox cv:lle, U,c (9(o) Loh, -- -898
Building Contractor's Company Name Telephone
F. b BoX 87 021 rAYETTEvtLLE NC. 2$30y ,3YS9P -,3
Ad r ess IV I r / License #
V W% Must sign & fill out second page
Sign ure of O /Contr fficer(s) of Corporation
Electrical Permit Information
Description of Work kle tLcj :e . „ea- Service Size: Zoo Amps TPole ye no
sQn14 Y�;�9@ r le r 3 taxc , $n c. (Rio) 3a3 -y a SB
Electritufl Cor>4ra G ctor's Company Name Telephone
List( Wk -f c. t Vd 40`,cl- itwllt x$3)2 1000(-,-U
Address
&\41\42 License #
Signature of Officer(s) of Corporation
Mechanical Permit Information
Description of Work New it El Caul:., $
r(NOSI-1 - A\ 14nc. (9 )0) 4154— (,S S
Mechanical Contractor's Company Name Telephone
sal o _ • _ _ .- c-u? 1 c. tioy 1 587
Addressc License #
Signature of Officer(s) of Corporation
Plumbing Permit Information
Description of Work A)tw fptv..6;.. # Baths 2-
1169n 77 #ACSWd P /, /L 4- 9i/ - 9,0 I 6xe4
Plumbing Contractor's Company Name Telephone
3c 4/r,t ern Pa D2 rill Ate . ,�83I6 773% - ,o
Address, License #
Signature of Offic r(s of poration
Insulation Permit Information
A -1 finsulci;,.„ P.O•13nx lib Npet613 NC. ).81 (cllo) 4,).9 -0990
Insulation Contractor's Company Name & Addrbss Telephone
Page 1 of 2 9/07
Application #
Please answer the followin question] o ee
then see Applying Bull Their Own Home
Technician determine _ _
Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo available upon cn req ua
u 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. 1 state the information on the above
contractors Is correct as known to me and If tiny 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 reSponsibplty to notify the Harnett County Central Permitting Departrent of
any and all changes.
Signature bf Owwne Owner/Co s of Co 7�Lr�1
() Corporation Dat
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
General Contractor Owner X Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury Ihat 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.
X Has one (1) or more subcontractors(a) 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 workers compensation Insurance prior
to Issuance of the permit and at any time during the permitted work from any person, firm or corporation
carrying out time work /' 1 ,
Company or Name: b ��.0. L�. \\ om tj n-C i o4'I.cVitl1
t� LL-C—
Sign Wilde: 'hp .$) no.vnt CoAna,n$o Date: 7 12..E / 10
Page 2 of 2 9/07