BUILDING or / scO 25 26o
rater contracmr. Address, company Harnett Central PBrmitlin
1
name & p Mne must match inbrtnatldn on I PO
Box n tyington. NC 27596 g
license. 910893.7525 Fax 910-893-2793 www.hamel orglpemdts
AtmlIq$lon for Resident$$ Buildirta and Trades Perm
Owner's Name: 13rsi- (3H:1 (Op s1-ri..cLIJ d'hcb ;ymi, Date: 9/2z /rd
Site Address:1t g P Mc ctio,..., St rn.9 Lo.ic i Swla) Phone: Via -- 3u l< -yi38
Directions to job site f Lillington: To Cure? Lin. t La k rs t r d n ., 0 - a-ra t
14) r I � 'c-14 ateadow Sirr.+5 LN'+G
Subdivision: l r.t roJ ;a,. (-- a,j1-l5 Lot 4 ('1 n
Description of Proposed Work: 5 r c #Bedrooms: L i
Heated SF 023 Fa Unheated SF 7 48 Finished Rec Room? Crawl Space () Slab (C) k o io
(�
r� General Contractor Information
(3r54 1j 1{ CcNsjr , i Q , - -r'Y , gib 308 -((538
Building Contractor's Company Name Telephone
50 ElI ;eft - 8r.a4t RA LatL, 4) L.2836 5741'1
Address ,,�.// License #
Girth t.r r.� Must sign & fill out second page
Signature f Owner /Contra t cer(s) of Corporation
Electrical Permit Information
Description of Work Service Size: Amps TPole: yes/no
3 1 2 /r1r-rr ' L _ a - 9 / o - 3 0 9 - 6 4 . 9 - 2
Electrical Contractor's Company Name Telephone
In ill 0 et. Cccr. L., "we L,' /lrnsfonu Ak .4 -1
Address ;2 75-44 License #
ids, re if Ow a.t
Sigr re of Officer(s) of Corporation
monankcjaWAUSjibbattalia
Description of Work
Tonto: 4 Tern of. I A A 4 Ai • r 1,•r env -4a4-171).2
Mechanical Contractor's Con'fpany Name Telephone
5.2 17 m « W a rs., m 14 mik NC anti? Il U iens e# 43
Address
Signature of Office ) of Corporation Plumbing Permit information
# Baths
Description of Work -
ar l /
T /��Z9
Plumbing Contractors Company Name IC
I I t r e ' • s License #
Address 27339
Si na re o Officer(s) of Corporation
g I rmu L on_ — O° f / b - t{ fr -
1 Telephone
Insutatio Contractor's Company Name & • . 'ress
8/21/08
Homeowners Applying to Build Their Own Home
Please answer the f000rdng questions then see a Permit Tedvddan to determine if you quality for pemdt under Owners Exemption.
Questionnaire per G.S. 67 -14 Regulations as to Issue of Building Permits (Memo available upon request)
1. Do you own the land on which this building will be -• : • __ yes _ no
2. Have you hired or • end to hire an individual to • _ • and manage construction of the
project? _ yes _ no
3. Do you intend to directly control : -• : construction activities? _ yes _ no
4. Do you intend to ached =, contract, or directly pay • : ' • y::: of construction work to be
done?
yes _ no
5. Do you i i. personally occupy the building for at least 12 consecutive months following
completion • construction and do you understand that if you do not do so, it creates the
presum • n under law that you fraudulently secured the permit?
_ yes _ no
I hereby certify that 1 have the authority to make necessary application, that the application is cared
and that the consbuctlah will conform to the regulators in the Buticlrg), Electrical, Plumbing and
Mechanical cam, and the Harnett County Zondng Ordinance. 1 state the information on the above
contractors is coned as known to one and if amt flanges occur including listed contractors, site plan,
number of bedrooms, bullring and trade plans, Environmental Health permit changes or proposed use
changes, 1 certify it is my responsibility to notify the Harrrett 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 current fee schedule.
A#I 4r : a air 91/4 jv
: l - of Omer • a
.., d s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
'( General Contractor K Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), fun(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.
_et Has one (1) or more subcontradors(s) who has their own policy of workers' compensation insurance
covorNhg themselves.
_ Has no more than two (2) employees and no subcontractors.
White working on the project for which this pent is sought it is understood that the Central Perm
Department issuing the permit may require certificates of coverage of worker's compensation meuance prior
a suance of the
ryl wt and at any time during the permitted work from any person, firm or corporation
Company or Namm 4 /� l
Sign Write: f Jr / / ✓G.., � Date: / /a Yee)
8/21