BUILDING z .
. • Each section below tobeMedanty Application ID — Sc)o 29 (Pe (
whomever palomino work. Must be comer
or acensedconbactor. Adds. company Harnett m Central Permitting
Hama & phone must match Info on PO Box 85 tiningtm. NC 27548
as 910193 -7525 Fax 9104932799 www.hamenorgipamps
ADDW'.BNen for Rtt Bu&dhre and Trades Permit
Owner's Name: j 413 M P ti ce. Co hs cc 0-1 ,1 r.c . Date: Y3 13 ) 1
Ste Address: 5 80 512r,.b nn -as At'i1 -ems Phone: ('f /o) 5 J4 - LIT 3c.
Ditecdons to job site from Lgkngton: than 97 k fa l'i■s„ wc(ch £ . ID cve6, .y.+ I fw- h ,cAC '
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Sub vision: CO- vc I fi nal &WS (415 Lot 34
Damon of Proposed Work: u ew I-k w-c, *Bedrooms: 3
Heated SF 22(0 0 Unheated SF Slip Finished Rec Room? ) Crawl Space ( ) Slab (IY
Kral Cord for NNonrmibn
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Building Cont actor'e Company Name Telephone
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ting Contractor's Company Name Telephone
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Insulation Contractor's Company Name & Address • Telephone
Page 1 of 2 3/018
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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 any 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 curr -nt fee schedule.
„�.. 14._ - • 3\ LO
Si• ature of Owner Contracor/Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
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.
H as 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: /' `- -)ek, f " P vi 1c (OV S+tC Inn `
Ch I vC'
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Sign w/TitI�V � Ud / 01 a ^a',cni Date:_ ') 3 t 0