BUILDING NC 2
Ea eaedon 4et to be Blbd out by I
of Scent combs tot. %/e* Address, company Application A lication # l � 0
• • I of Scented eo116eetar. Addre tympany PP
name 6 phone must match Intimation on Box 8
rnett unty Ctraermitt
Ikx+nN. PO 6 Ullinpton, 7548
870. 883.752 Fax Co 810.883.2793 en www P hame8.org/pe ing rm8s
Aaallcption for Residential Building and Trades Permit
Owner's Name: Lo r nl C•re 9 7-0./ or Date:
Site Address: J °id Hwy 'let Phone:
Directions to job site from Liliington: 7T4-kc OM I/21 440,4 t rn,Jtr
0,1- eTr `:I). -�--, 1-fa,( (t v- e ica acruiS err
14 Q- ') • lcc4 -'cc 54,
Subdivision: Lot:
Description of Proposed Work: #Bedrooms: 3
Heated SF Aga» Unheated SF Finished Rec Room? Nn
Crawl Space ()Slab (t
General Contractor Information
1 1er5 Tr�ILA e'S qlq -lab - 5/06 Building ontractor's Cony Name Telephone
?n 5n)1 S 7.5 riA l 1 A a l5 o-
Add License
Signature ofi OwnerlContractor /Office of Co Must sign & fill out second page
Ks ) Corporation
.. '.9.1 = 111 1 1 l' 111 1 • 1
Description of Work , 'al .. l# ervlce Size: ,, 4. • mpg TPo$ C
:: no
�y'�) o✓)tD rdP a P £O art . 9 -/q1_
Electrical Contractor's Company Name Telephone
4/1-, j(°,S); tL rr-/N( cs2 7?. ?7 /9 no7 -0
yddre yy e �� s ,�,� License #
4 �� (yy Signature of:Offlcer(s) of Corporation
Myc hanicalfHVAC Permit Information
Desaiption of Work no t n r ec; r•IPr140. 1
E ijOrcir PPrI in Pr9 ci C``'. 1?(0 9,5 to0
Mechanical Contractor's Company Name Telephone
3 Ss.sgOS 16Jt,� y l I f. AshaboroNC 617 aa3
ddtess License # ille 250 *alit
Signature of °Moo (s).of corporation
Plumbina Permitanfonnatloq
D i t s c d p t i o n o f W o r k f & V P r PS / r (,o ,.,4l I f Baths
3 Cirni e TSORnco n7)utnbl' qt0— k/N- 77ris
Plumbing Contractor's Co__mgan Name J Telephone
. ) 0 mCIarK 1 I.;)i i n54.n h Wed 726 (11.0',
Address
License #
S ature of cer(s) of Corporation
Insulation Parmlt Informatioq
!, s 4. . .r • 3 4
/ V 1 .r • . a a 8 Q - rj
Insulation Contractor's Compan Name & Address EA t , 1) t NC Telephone
8/21/08
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? f 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 ate( 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 as per current fee schedule.
4g /D /a - /O
Signature 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 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:
9 Has three (3) or more employees and has obtained workers' compensation insurance to cover them.
,J 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 any time during the permitted work from any person, firm or corporation
carrying out the work. 1
Company or Name: ( (rofcrIe5
Sign w/Title: 7Zt»t1 I Date: /0 'J - 1 &
•
Residential Building Application 2 of 03 /10