BUILDING • Each section below to be filled out Application # l ✓ ✓ ✓' 2 ��, 6
by whomever performing work. Harnett County Central Permitting
Must be owner or licensed PO Box 65 Llllington, NC 27546
contractor. Address, company 910 -893 -7525 Fax 910 -893 -2793 weww.harnett.orglpermits
name 8 phone must match
Application for Residential Building and Trades Permit
Owners Name: Mickey McQuain Date: 9-24 -10
Site Address: 25 Brae Drive, Lillington, NC 27546 Phone: 910.303.1967
Directions to job site from Lillington: Take Old US 421 North from Lillington. Subdivision is on left (Ross McRae Brae)
1st Lot on left.
Subdivision: Ross McRae Brae Lot: 1
Description of Proposed Work New Construction / SFD # of Bedrooms: 3
Heated SF: 2535 Unheated SF: Finished Bonus Room? I Crawl Space: ✓ Slab:
General Contractor Information
Thomas Construction 910.893.8950
Building Contractor's Company Name Telephone
229 Oak Si, Lillington, NC 27546
Addre - Email Address
/ . / !.iu! A - ii. 17963
• Sign- Tire of Owner/Contractor/0 e jl I T! of Corporation License #
Electrical Contractor Information
Description of Work New Construction I SFD Service Size: 200 Amps T -Pole: 1 Yes No
Dawson's Eleatic 919.201.3841
Electrical Contractor's Company Name Telephone
3754 Cokesbury Rd., Fuquay Varina, 1,C 2726
Address � Email Address
Jar / 25948 -L
Si• ure of Own c ontractor /Officer(s) of Corporation License #
MechanicaUHVAC Contractor Information
Description of Work New Construction / Heat Pump
J & M Heating & Air 910.897.5501
Mechanical Contractors Company Name Telephone
724 Turlington Road, • - ts, N 28334
Address Email Address
jj�� // i 17164
Sign. ure = 0 - r /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Construction / Septic # Baths 3
Wagner Plumbing 910.893.3050
Plumbing Contractor's Company Name Telephone
PO Box 494, Mamers, NC 27552
Address / Email Address
G � 07674
Signature of O,tr /Contractor.'fficer(s) of Corporation License #
Insulation Contractor Information
TriCity Insulation 910.486.8855
Insulation Contractor's Company Name 8 Address Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine it 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 personalty occupy the building for at (east 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 aan 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 a • -'. • rrent fee schedule
i1 A'T ✓ n: r L re/ „ba b j y !O
ignature of Owner/Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
General Contractor Owner I 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.
1 Has one (1) or more subcontractors(s) wtro 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 any time during the permitted work from any person, firm or corporation
carrying out the work.
Company or Name: Stephen T. Milton
(lelk
signwlT 4f ) 9 -24-10
ltle: r (pot Aa�'iaa, Date: