BUILDING • Each section below to be filled out Application # 0 5 24 :if
by whomever performing work. Harnett County Central Permitting
Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910 -693 -7525 Fax 910 -893 -2793 wvnv.harnett.org/permits
name 8 phone must match
Application for Residential Building and Trades Permit
Owner's Name: Milton Enterprises, Inc. Date: 07/21/2010
Site Address: Lot 28 The Vistas - 226 Braddock Dr., Lillington, NC 27546 phone: 910.303.1967
Directions to job site from Lillington: Take 421 S. towards Dunn. Tum left on 27/ Old Stage Road. Approx. 1 mile
turn right onto Braddock Dr. (The Vistas). Will be the fifth house on the right.
Subdivision: The Vistas Lot: 28
Description of Proposed Work New Construction / SFD # of Bedrooms: 3
Heated SF: 2200 Unheated SF: 947 Finished Bonus Room? I Crawl Space: 1 Slab:
General Contractor Information
Thomas Construction 910.893.8950
Building Contractor's Company Name Telephone
229 Oak St., Lillington, NC 27546
Addres�J 9 ,----- Email Address
( � /• 17963
Signature of Owner/Contractor/Officer(s) r poration License #
Electrical Contractor Information
Description of Work New Construction / SFD Service Size: 200 Amps T - Pole: 1 Yes No
Dawson's Electric 919.201.3841
Electrical Contractors Company Name Telephone
3754 Cokesbury Rd., Fuquay Varina, NC 2726
Address / Email Address
i .e
Signature o Owner /Co !or /Officer(s) of Corporation License #
Mechanical/HVAC Contractor Information
Description of Work New Construction / Heat Pump
J & M Heating & Air 910.897.5501
Mechanical Contractors Company Name Telephone
724 Turlington Road, Coats, NC 28334
Address Email Address
17164
Signet e of Owner/" tractor/Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Construction / Sewer # Baths"
Wagner Plumbing 910.893.3050
Plumbing Contractors Company Name Telephone
PO Box 494, Mamers, NC 27552 910.893.3050
Address Email Address
r( 07674
Signature of 0 /Contractor/0 s) of Corporation License #
Insulation Contractor Information
TriCity Insulation 334 East Mountain Drive, Fayetteville, NC 28306 910.486.8855
Insulation Contractors Company Narne & Address Telephone
'NOTE: General Contractor must fill out and sign the second page of this application.
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Perini 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 (east 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 anv 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 5150.00. After 2 years re -issue fee
is os p current a sct
07/21/2010
Signature of Owner /Contractor /Offs ^ s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
General Contractor Owner 1 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.
1 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.
e• . • - Construction
Company or Na i
�i ia _. j4= 047Y AG rNotrite
Sign w/Title: if grpRESEN774y'S v9 Date: /21/2010