BUILDING Il
4 r2aach ° st Lion below to be filled out by Application t!1_0_m
a is/ 9a_
or acecensm_.:er. t :v work. Must be owner Harnett County Central Permitting
or ntractor. Address, company
name - phone must match information on PO Box r L -n -7 NC 27546
licens @. Telephone Number 910- 893 -7525 wwryv.harnett.org
Application for Building and Trade Permit
Owner's Name: S*PrPnSp 1,` it\c\ty - S 2 n!_. Date: - 13- in
Address: G'u t.Uinj'rf fit &kw.t -cl (ACC Phone: (o'i9
Directions to job site from Lillington: alb '-vo'.O -,rcl _SDt�1.. LciVo �S rvW •
Lef c- t "- L'.55r3r -r qr-t . L-C** o \ n (,, )On eel- r6))/". Subdivision: Wc>,thvl Gneove Lot: I a
Construction Type: (Please Check) Building Use: (Please Check)
_ ✓New _ Moved House ,(Residential Commercial
--
Renovation — — Other — Modular _ Multi - Family
Total Project Cost: (70 Description of Proposed Work: NevJ SOrtt �'Gtwit,'
General Contractor Information J
Heated SF _Crawl Space () Building Construction Cost $ c DJO
Unheated SF Slab ( ) Acres Disturbed . a Stories Oa
<-1‘e R. i l d crs r (e 39 - .D X
Building Contractor's Company Name Telephone
1 rd RAN r,19, ,Sfi• ft-c.o��cir t4(- Di Not .S3(
Addre License #
� r
Sign re cif Own o ractor /Officer(s) of Corporation - Must sign back of form s workers comp
Electrical Permit Information
Description of Work 14 (2)A/ Electrical Cost $ $ ?nn
TS Pole: Yes ( No () Underground (i Overheard ( )
Per ,)/
Permanent Service: Underground tl Overhead ( ) Service Size: aoo Amps
( >an £ kr.h - c c 4 ; 9 - .SSa- cos aE
Electrical Contractor's Company Name Telephone
.Ct . ... C•• _' .. in 1 -1 5798
Address License #
Sign tur f Officer(s) of Corporation
Mechanical Permit Information
Description of Work ACV/
Number of Units a Type System tkclv-C Mechanical Cost $ spud
3 C3 I +if-( cICt - t coa58
Mechanical Contractor's Company Name Telephone
t55r0 jc.dc Klreltvt1 - r.,, R.c(. MAUI S 7S''LO lace (-f - 3
Addre /� License #
qq l /nerd{
Sig roOff ci er(s) of Corporation
Plumbing Permit Information
Description of Work rI.PJ✓
Number of Baths ,3 Plumbing Cost $ 5(1 )0
WIAI P1ur4.rte ='nc ° n e t• le 3et - DlGS —
Plumbing Contractor's Coi ipany Name Telephone
gp I nnc Arn5I - e r• a-7 SO1 JL-1 UFS i
Ad ss J License #
atur of Officer(s) of Corporation
Insulation Permit Information Residential () Other ( ) Not Required ( )
^ I E
‘,/,c, ‘,/,c, ri G'y1nt 2VY,C ( Qr. l.oitln\ Vr. 2fa I..:H rk - ,.rr c �--t . r.nz �'f19 - a - ' (Oa
1_) St R7D- 'j ocO
—
Application?I_ -- __ --
Commercial Jobs must fill out this portion
• , 1 Sprinkler System Information
—
Sprinkler Contractor's Company Name Contact & Telephone
Address License ,
Signature of Officer(s) of Corporation
Fire Alarm S - em Information
Fire Alarm Contractor's Company Name Contact & Telephone
Address License #
Signature of Officer(s) of Corp. ation
Driveway Access - NC Department ofTransponation Driveway Access /Permit? Yes No
I
Homeowners Applying to Build Their Own Home
i 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 • -rmits (Memo available upon request)
1. Do you own the land on which is building will be con- rutted? yes — no
2. Have you hired or intend to hire -n individual to s .erintend and manage construction of
the project? yes no
3. Do you intend to directly control & supervis= construction activities? yes no
4. Do you intend to schedule, contrac , or . irectly pay for all phases of construction work to
be done? yes no
5. Do you intend to personally occ -py t e building for at least 12 consecutive months
following completion of constru '•n and do you understand that if you do not do so, it
creates the presumption und law that yiu fraudulently secured the permit?
yes no
Sign & date 1 .
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,
building and trade plans,7Env onmenta ealth permit changes or proposed use changes, I certify it is
my responsibility to notif th I arn: tt if runty Central Permitting Department of any and all changes.
( 9 - 13`/0
Signature of Owner /Con actor /0 i of Corporation Date
Application to. 500_)49a% — -
Affidavit for Worker's Compensation
N.C.G.S. 87 -14
The undersigned applicant forBuilding Permit # 1 l7 ,1 a`( so 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 /have three (3) or more employees and has /have obtained workers'
compensation insurance to cover them.
Has /have one (1) or more subcontractors(s) and has /have obtained workers'
compensation insurance to cover them.
t Has /have one (1) or more subcontractors(s) who has /have their own policy of
workers' compensation insurance covering themselves.
Has /have not 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.
Firm Name: Skrp\en ;lA S 1in�
( f
Sign /Title: �a4_d% (ir. 1/t(c. (44
Date: (� _ I ' J ' I( y,
•