BUILDING ..
= • tseatlon below to heMed out by Application a l0 5 2 4 l Z
whomever p®Io a work Must be owner
«Bcensedcontactor. Address, company Harnett County Central Permitting
mattea phone must etaoit6damtadaton PO Box 85 tomNC27548
, tiatg 918. 899 -7529 Fax 916896.2793, Mww.twmettorglpemtfs
Owner's Name: . J BC Dtkeetiae.rs I n r. Date : B) 3 o) i o
Site Adder: 45 Ike Wire Co IAA- . Phone: 914 - 423 6
Directions to job site from Langton: Pull i n+o (nw+e s . g) en Mar!( 1.4,:c
(13 hp, 124.1 fr. ...lP ) (b onto 6.444 r ...r • (1.) twig Dian 4144.4....
(Pi A+ a) < i ci.t oF at' -dr - Silt .
Subdivision: 6M-es P l.Gxinrr, Plaritr •0. - Lot 24"
Description of Proposed work: Nat) }}o *Bedrooms: 5
Heated SF 21729 Unheated SF 4 20 Finished Rec Room? yf s Crawl SpaceXSIab ( )
Oenaml Contractor In(orntallon
JGSuv) Ghu Coln *nacho, ,)nc. gig-4234
Building Company Name Telephone
110 pt S s4 Li II it in, Ili S o85q
p License #
` / V A .�.f! lA J C .v taust sign a 69 out second page
irSitipetdrteee of Owns AO(fioer(s) of Corporation
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Desalption of Work New Nov. -4_.
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1 bing Contractor's Company Name Telephone
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Ucense #
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Insuon Contractor's Company Name & Address Telephone
Page 1 of 2 9/08
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 my 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 c'rrent fee schedule.
f U W) r,l�: SJ 3o), o
S na a of Owner /Contractor /O er(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.
Company or Name: Jason Price Construction, Inc.
Sign w/Title: cj A C,u) Date: g/ 3 t,) 6 V
Residential Building Application ?of 2 1)3/11)