BUILDING ' Each section below to be filled out by
whomever performing work. Must be owner I — 7 (�/
or licensed contractor. Address, company Application # f ? /)
name & phone must match inforation on Harnett County Central Permitting
m
license. PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 - 893 -2793 www.hamett.org /permits
6 '.-1
A. • lication for Residential Bui din • and Trades Permit 0 ..., 1.
Owner's: Name: S , t . . , o i�
�� - sic r _ D a t e: q' 7� /t)
Site Address: /Y _ jflj LJ W4 A/004 Phone: (9/ ?)77S-3907 V
Directions to job site from Liliington: /9 v' o, epee it C' /ub — 'Mkt
O jt\ \
C lksirttc]F%o e� 6 o/ /1 iec. 4c / / ON ewiio✓ / Cwiv
1t <t ON day t i!fse
/M c *4 War /✓off • 1'J�r ` /i , fja c e oN //L
Subdivision: 444)-S L k C ILI
Lot: _frip
Description of Proposed Work: /144,./ Ca J fru id 0%) #Bed 3
rooms:
Heated SFc7y3 Unheated SF IV.? o? Finished Rec Room? Vt.'
t General Contractor Information Crawl Space yf Slab ( )
0 i -chow a s Jo,es tesJJ4ia� La. V9- 795 -39a a
Building Contractor's Company Name Telephone
/070 7 / /on7 t1 /. / 4, 4 iv ( p $ sa2cR
Address . i/
/ "� ` j License #
r
Signature er /Contractor /Offi of Corporation must sign 8 fill out second page
�(s )
E Permit Information
Description of Work ,V,9 ��$ A S Service Size: 1
a Amps TPole: no
C it ry .S" Iv efr i C,. . 14 e . c17E ,> , - / at S' 3
Electrical Contractor's Company Name Telephone
Address �d k 3 3 c.4e i t ! .4i.,e__, .P.', .." / _I /O S 5 I - L
lire * C� ` 6 License #
Signature of Officer(s) of Corp ration
Mechanical/HVAC Permit Information
Description of Work ilk ' i
Mechani .1 Contractor's Compa r N
3
�3 � Telephone
Address $4' k rh d/. P. ,i , z/ ?-75 /8 6 V5
.- rj ` , License #
Signature of Officer(s) 421
; , > f Se
er(s) of Corporation J
Plumbing Permit Information
Description of Work !M„{ k.r.is-n Qi) # Baths
UIS ILimiiSriu - Co.o 2.me'iA)6 -,, I xi( e /io— Li •e.g°5 `
Plumbing Contractor's Company Name Telephone
ephone
Address i\IC. f 1Y
License #
at 7 - . • icer(s) of Corporation
>e"lsAt <.J Insulation Permit Information
Insulation Contractor s j `�f �' / 7 ?
piny Name & Ad Telephone
l �
''ki rryc 41:1 4 7S
8/21/08
Homeowners Applying to Build Their Own Home
Please answer the following queettbre then sera Penne Technician to determine if you under
Questionnaire per G. S. 87 -14 Regulations as to Issue of Building Perm its (memo ava Exemption.
Pa 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
1 hereby certtfY that I have the authority to make
and that the construction wit cortfbrrrr to the necessary application, that the application is correct
regulations In the Building, Electrical, Plumbing and
Mechanical codes, and the HameK County
contractors is cornet as known to me H Zon Ordinance. i state the information on the above
comber of bedrooms, buildl changes occur including listed contractors, site plan,
changes. I c my respond trade plans, Environmental H permit changes or proposed use
e ang it ism responsibility notify the Harnett County Central Permitting Department of
any and cert it
EXPIRED PERMIT FEES - 8 Months to 2 years permit re -issue het, 1180.00. At ter 2 years re -issue fee
is as per current fee schedule.
t
Signature
/Officer(s) of Corporatlon Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned 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.
_X_ Has one (1) or more subcontractors(s) who has their own policy of workers' compensation i
covering themselves. saon lnsuhartce
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 Permittin
Department issuing the permit may require certificates of cover 9
carrying out of h e w o rk rt at any time during the permitted w ork o /rom ark insurance s h Prior on
Company or Name: ; 0- ,,,
Sign w/Title: // •
/ - P , ss•.► i-
Mar
Date 9- 7 -1 on
s/21 /08