BUILDING Application # 10 '5W�.I b 1
*Each section below to be filled out Harnett County Central Permitting
by whomever performing s work. PO Box 65 Lillington, NC 27546
or licensed
be owner or licensed 910- 893 -7525 Fax 910 - 893 -2793 www.hamett.org /permits r an\u nae company 1 ' name me & p hon must e must match �/"
Application for Residential Building and Trades Permit c�
Owner's Name: 1-4I'( C- Q L'" I,) e -11,41 -e 5 LJ- C Date: / �o ''
Site Address: e) ��ir�� / > v � � /t' e.....4.---e____ Phone: i e7Y 172 177�J p
Directions to job site from Lillington: 66 fe / d ho ii i e.5 70 /4r°'if 6
R ? 4,74 - 7 1 .,)/b 1 /e-
I / �14 2 !.e- ,, te /e t�.� -e 4613 f M
Subdivision: L /)114 A4,49S /i_ 1 ikV Lot: ' It+.
Description of Proposed Work: A / e► 7'ketz-41-) J-P /Q eS,G€eZc;4# of Bedrooms: `,4
Heated SF: 29f Unheated SF: `7 Finished Bonus Room? ,t-. Crawl Space: Slab: ✓
R Mpt-e General Contractor Information
ti/ / / � /// ; l ` 5 - 3 177 //7 $
Building Contractor's Company Name > ���ZA-, Telephone dJ
Address _ ' '� Email Aess
Si nature of • i - r ontractor /Officer(s) of Corporation License #
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.Electrical Contractor Information 6 pee)
Description of Work 45;c44 /G Service Size: 2 ov Amps T -Pole: /Yes No
Too / 7,.:., E1ec.T.2-:c Co. �N 9t9 5 9 /vv
Electrical Contractor's Company Name Telephone
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Addr ' / / Email Address
y _- / 37 /V-L
ign- • - z n : r/Contractor/Offi• r(s) - e 'rporation License #
Mechanica /HVAC Contractor Information
Descri tion of Work ig . c e , � l t ". - /3 n $fig 67't 7
Mechanical Contractor's Company Name Teleph one
571 � y 4i : 1 ( A/G G' ?6'I/' loc644/1) /kS • c. 7
Address F3 i' , Ema'I Address 0,2,4-/---5
-, , Signature` Ow ner /Contractor/ icer(s) of Corporation License #
Plumbing Contractor Information
Desription of Work ,Xe. / 7 7 ( / '�Ls . ,: /N5 # Baths _
/ r / - • 44--e _ 707' 4 Z5 oZ
Plumbi• _ Contractor's •mpany Name Telephone
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Addr "�� Email Addre
. `1.s31
License #
Sig ature of wner /Co reCtor /Officer(s) of Corporation
Insulation Contractor Information
Email
i .f.a 9o,J Li S cAth 2®, ci- cam4 daavecit 9/J 6. / - o 99f
Insulation Contractor's Company Name & Address ' Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Residential Building Application 1 ;,t 2 '1511`.)
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 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 Harnett County Central Permitting Department of
any and all changes.
EXPIRED r - ' FEES - 6 Mo the to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is as pe current fee schedul:.
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Signature of Ow( /Contractor /Officer(s) of Corporatio 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.
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 as ' - during the permitted work from any person, firm or corporation
carrying out the work.
Company or Name:
Ai
/ i D ate: '
Sign w/Title: �� /0 �, '
Residential 8uiidir'q Application 2 of 2 03!1 u
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