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BUILDING *Each section below must be filled out by Application# 1(2 '7 10 2 7 P C Harnett County Central Permitting whoever is performing the work. Must be owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546 company name & phone must match 910- 893 -7525 Fax 910- 893 -2793 www.harnett.org /permits information on state license. COMMERCIAL , Application for Building and Trades Permit Owner's Name: (ie- s Co.s i wi Date: i f dl (c o Site Address: 2 15 w. M c ki461 Sh Co.-is 1-1S21 Phone: °(I - 868- 2442 Directions to job site from Lillington: Hui 21 to C.o at / Ck+a" e'rn a i.t+ea•-s , }P I7 4 SS Subdivision: Lot: Deseription,of Proposed Work: 4. n 4. "' go' toes Heated SF Ii ik Unheated SF IJ(A- Pope, pp General Contractor Information: Building Cost $ � . 3 9 t ao • Pope, Bun Q.tnr Pt- 8& , -met, Building Contractor's Company Name 1 Telephone (3OJ Wtllo• c DJhn (•& Z{ 33 f roteY+ 5 yfr . [.o Addres Email Address 40584 . Signature of Owner /Contractor /Officer(s) of Corporation LDense # Electrical Contractor Information: Electrical Cost $ f "Coo. Description of Work 1-14d/nr /r »4-/; ¢ Rece PI - ill BMAService Size: Amps #T -Poles 44 /ec fni . c4( So /U) oi'r5 / /4 • a22-2 - Electrical Contractor's Comp, ny ame Telephone 9'©2 Fr- Ad /y Du na 4)C a'i 33 7 de .elc VC- � 7ve '.(° - , Address Email Address Si ature of Owner /Contractor /Officer(s) of Corporation License # Mechanical Contractor Information: Mechanical Cost $ It. -- Description of Work 414 Qom' Pal Vent. d ;1 urS # Units . Jai S 4 i (ehi 4in i u,r�4 co s.-NE, e efregf cis Mechanical Contractor's Company Name Telephone St"( 410 /SV,e,) /u•.7 0 - 6 ea AL °N( /M Address . Email Address Signature of Own rr Contractor / Officer(s) of Corporation License # Plumbing Contractor Information: Plumbing Cost $ ja- •cJ De ri of Work 7 5 1 a%- L /ro<,,., / 213.v.. - 6 t # Baths I / .,. 0 , 1 6",;,, ‘ 9 89* Soo / Plumbing Contractor's Company Nam Telephone 2o. 80 /0 S Ca / ,'U. Address /� Email Address Signatt'ire of Owner ontractor/ 'cer(s) of Corporation License # f ' Insulation Contractor Information Insula Company Name & Address Telephone * NOTE: General Contractor must fill out and sign the second page of this application Commercial Building Application 1 of 2 3/10 -1 Sprinkler Contractor Information Sprinkler C ontractor's Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Fire Alarm Contractor Information Fire A (At Contractor's Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Driveway Access - NC Department of Transportation Driveway Access/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 Ally 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 char ed at full price per current fee schedule. Si ature of Owner/Contractor/Officer(s) of Corporation Da J Affidavit for Worker's Compensation N.C.G.S. 87 -14 The and igned 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. Ha ne (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover them. 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 ny time during the permitted work from any person, firm or corporation carrying out the work. �Qj Company or Name r 'r' /' 144 Sign w/Title: ifiA 1 6" Date: 9 (S ((° Commercial Building Application 2 of 2 3/10