BUILDING ( n 9
• Each section below to be filled out by Ap}1t1cHti.
on f/ /� .! `' O 7 1 �7..e vfiamever performing work. Must be owner Harnett County Central Perrnittin
or licensed contractor. Address, company g
name & phone must match Information on PO Box 65 Ullington, NC 27549
license. Telephone Number 910-893-7525 ww.v.harnett.org
i s i A II Lion for Building and Trade Permit
Owner's Name: -O�_- • J LLC Date: ' ( 4 0
Address: Phone:
Directions to job site from Lillington:
Subdivision: t SJtiKwo- -E— Lot: g'g
Contion Type: (Please Check) • Bui l�I' Llse: (Please Check)
`� Vew Moved House _✓Residential _ Commercial
_ Renovation _ Addition _ Other Modular _ Multi - Family
Total Project Cost: Description of Proposed Work:
General Contractor Information •
Heated SF _Crawl Space ( ) Building Construction Cost $
UtadSF� Slab () C Acres Disturbed Stories
ul r d GtOtt i / « L o 1 �.0t / Cu__ 9/0 - 989 -6VoV
B ding Contractor's Company Name r Telephone
O. 0 ayo R I GL y FJC� �9 3�- ro /64
Ad� / / ' / L ic ense #
an' /r < • _V ! -
- gnature of • ner /Contractor /Of lcer(s) of Corporation – Muet sign beck of form & workers comp
�
El ctrical.Permit Information .
Description of Work 'crt / • /✓arX Electrical Cost $
TS Pole:. Yes ( ) No ( ) Underground ( ) Overhead O
Permanent Service: Underground ( ) Overhead ( ) Servlge Size: Amps
•
h aw ��7•�Y e bri•vof/avlotLP ('a,z,4, 9/9 - 999- ?Pe. 7
Electrical Contractor's Company Name Telephone
'Of er n fl G 2/6 5'3 - / 4)
Addre � License #
Signature of Officer(s) of Corporation
•
Mechanical Permit Information
Description of Wotk – .
mber or Unite Type System Media ical osr3
• ' • - • Ji. -
e f ,nmalCar - :c se . C•m any Nem e ph•nq •
,,,r ILL k _ 3 _( u ,.c Alt ��
Sd Ire of Officer(s) of Corporation
•
Plumbing Permit Information
Description of Work 1 ' I. t • r A l •
Number of Baths
knit: a. Plumbing Cost $
ZtRnt i Jo , P iV nib /J
Plumbing Contractor's Company Name Telephone
) QJ m -k tE) L o i n 4 r 'J -C 75ft r 9 /
Address O License #
ae eofthcer(s)ofCorporaton
Insulation Permit•lnformation Residential ( ) Other ( ) Not Required ( )
Insulation Con - actor's ompany Name & Address Telephone .
Page 1 of 3 1/07
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 EES - o tus to 2 - ars permit r= issue fee is $150.00. er 2 years re -issue fee
is as per rrent f s e
r I ' tior f1 S /o
Signat e of Owner /Co ractorlOfficer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
\ V--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.
V ----Has one (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover
them.
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: /\� /'��J � /J � t
• Sign w/Title: /�� �. J t !` f Y Date. 8 6i l_
1 �
Residential Building Application 2 of 2 03110