DOCUMENTS r y whomever pe tom ing work. Harnett County Central Permitting ivpiicauon __
Must be owner or licensed
contractor. Address,company 910-B93-7525 Fax 910-B93_2793 wti w.ha nett.org/permits Is��3 7aS�
name&phone must match
A.g lication for Residential Building and Trades Permit
Owner's Name: /�j ../4.1 `�C //�
Site Addres L G� Date: C/ ��j_
Directions to lob site fr S pone: /-�}�� ='
�A nit illinalon: ,
r
Subdivision: Adingr ��� �i __
Description of Proposed Work: • �'�.� Lot:A 3
Heated SF: Unheated SF: D r_5___ #of Bedrooms:___
Finished Bonus Room?
General Contractor Informati Crawl Space: Slab:
Building Contractor's Company am' 1a__ (
./v- -ro_ ,` Telephone / /
..d= imir ail Address
Sign--!e of Owner/Contra tor/Officer(s) of Corporation
Elec ica Con ractor Information License#
Desc '-tion of Work ,,e, •
p j - i���� Service Size-...._ / Amps T Pole:
Zes No
Electrical Contractor's Company Name '� 9/9- � 4q-, .�Qq
a, _": _ �C Telephon
Addre / 'i' -•.-
Emai Address
Signature of Owner/Con rector/0 cer(s) of Corporation
Mechanical/HVAC Contractor Infor a License#
t
De ,;pion of ojk _ ' 1 i' ap,
4111 - I• / / _ - D F.
-
,10
feleph-Mecn_:cal :o ntraC[� s Co pan ern e �/?j/, ' _ OIC? J ; . 40 , f Addre : /
•
_ -JO
email Address
Signatu e . '1!'gf�r (� I
on a c ode -cer(s) of Corporation
/ Plumbin• Contractor Information License
Description of Work /�(' .Or1
r45 /4/ #Baths
Plumbing Contractor's Company Name if
Telephone
. . .f..i.i_. C
Ad,Add -ss
/o �� o
..- s Email Address
Signature of Owner/Contractor/Officer(s) of Corporation ��o
'^^• lation Contractor Infor tion
License#
� ,
Insulation C�:"ractor mpany Name&Address 1-goo
4-1‘-`' 7/(& .. Telephone
'NOTE: General Contractor must fill out and sign the second page of this application.
--
Homeowners A
PP�Ying to Build Their Own
Home
Please answer the following questions then see a Permit Technician to determine if you qualify for
Questionnaire per G.S. 87-14 Regulations as to issue of Building Permits (Memo available upon re uelst
1. Do you own the land on which this building will be constructed? Yes q )
es 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 Hamett County Central Permitting Department of
any and all changes.
EXPIRED PERMIT FEES- 6 Months t. 2 years permit re-issue fee is $150.00. After 2 years re-issue fee
is4aio. ent fee schedule.
Signatur_4' Owner/Contractor/Officer(s) of Corporation Qat t
e
Affidavit for Worker's Compensation N.C.G.S. 87-14
The and signed 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.
Has one(1) or more subcontractors(s)
covering themselves. ( )who has their own policy of workers' compensation insurance
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 -: _
Sign wait-
... '
Date:
Residential Building Application
2•Df 2
08/10