BUILDING Application # !o ✓7 A/ 24 f,A
• Each section below to be tilled out Harnett County Central Permitting whomever performing work. g
Must be owner or licensed PO Box 65 Listngton, NC 27546
contractor. Address, company 910 - 893 -7525 Fax 910 - 893 -2793 www.hamett.orglpermits
name & phone must match
Application for Residential Building and Trades Permk
Owner's Name: J & S Development Date: 7/19/10
Site Address: 15 Wateredge Ln. Phone: 910 987 0692
Directions to job site from Lillington: Carolina Lakes; left on Carolina Way; lot on corner of Carolina Way and
Wateredge Ln
Subdivision: Carolina Lakes Lot: 438
Description of Proposed Work: New Construction # of Bedrooms: 3
Heated SF: 2331 Unheated SF: 775 Finished Bonus Room? d Crawl Space: d Slab:
General Contractor Information
J & S Development Co. 910 987 0692
Building Contractor's Company Name Telephone
1172 Vic Keith Rd. Sanford, NC 27332 jandsdevelopment @windstream.net
ress � Email Address
`j�(1/ NC 56822
re of Own ntractor /Officer(s) of Corporation License #
glectrical Contractor Information
Description of Work New Construction Service Size: 200 Amps T -Pole: ✓ Yes No
Ringled Electrical Contractors 910 237 5690
Electrical Contractor's Company Name Telephone
P 0 Box 65074 Fayetteville, NC 28306
dress Email Address
20555 - L
Ig atur Owner /C radar /Officer(s) of Corporation License #
Mechanlcal /HVAC Contractor Information
Description of Work New Construction
James Hayes Heating and AC, Inc. 910 484 7155
Mechanical Contractor's Company Name Telephone
620 Fair St. Fayetteville, NC 28306
ddress Address
20051 H3 -C1
turerof caner /Cant or /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Construction # Baths 2.5
Chris Holloway Plumbing Co. 910 624 2670
Plumbing Contractor's Company Name Telephone
737 Old NC 20 St. Pouts, NC 28384
dress Email Address
28541
Signature o caner /Contra r /Officer(s) of Corporation License #
Insulation Contractor Infomtation
Insulating Inc. P O Box 2741 Sanford, NC 27330 919 776 4138
Insulation Contractor's Company Name & Address Telephone
`NOTE: General Contractor must fill out and sign the second page of this application.
Residential f3oilding Apolicaf,nn 1 of 2 oat 1C
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 Hamett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and if y 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.
//
Si. • - o • er /Con or /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.
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.
Company or Name: J & S Development
Sign w/TitlC--- Date: 7/19/10
Residential Building Application 2 of 2 03.11