BUILDING Application # /2 J a,9 7 O r
• Each section below to be filled out Hamett County Central Permitting
by whomever performing work.
Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910- 893 -7525 Fax 910- 893 -2793 www.hamett.orglpermits
name & phone must match
Application for Residential Building and Trades / Permit 7� ) /
Owner's Name C�h>f�y�� 'de( 0 ( A /4( e _ LI A VC Date: / v " ("(' i h
as 7 ddl/ h k l 7 A /l f/ 2
Site Address: 0 L— • ► Pho -, / &K
Directi • job site from LillingtonT v (-0 A 2, . .4„ 9 .e isfri � !iI. �r t
" ,1 I II t s ' . (���►S I 11,r _ i l _ i ' Olite.
lii � � ' ilia
7 r •
SL bdivision: Lot:
Description of Proposed Work: T rt Go, -n9t_C t Re parr' # of Bedrooms: 1
•
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: Slab: _
General Contractor Information
45 ad /nor j
Building Contractor's Company Name Telephone
\Idr Email Address
SiVur- of • er/ :tractor • Icer(s) o Corporation License #
Electrical Contractor Information
Description of Work • ` ' N . , _ ' ervvEmsice�Siize: Amps T -Pole: _Yes No
1 rfr () /A-ac, _ i g"f„ " ?-•' / r! ` 7-5-6— Z F%y
Elec trical Contractor's Company N Telephone a
lll //�V �c z T �Z/fGO -Fe
Email Address —
. s s /c C ' ' 4 o ` ` 4 - r r � , � C . 2 7 s t r 7 7 7 7 L 0
nature of wner/Contractor/Officer(s) of Corporation Licen e #
?o Mechanical /HVAC Contractor Information 'o ,(
Description of Work c�f /lit (A -1�IJ/ / 4
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(o( %t; ff ¢/ T z- a -- - � ?7� — z h"3 —. ,,, y
Mechanical Conaacctor's Company me Telephone
tft C J , V 2 / /. Vv -- y 4-C- 2�re''r -0
Add / Email Address
Pte/ // '(,ca - t ° ��s Y a
Si re of Ow er /Contractor /Officer(s) of Corporation ense
Plumbin! Contractor Infor , "•
Descri.tio• of Work ! # Bath
fI . 15n u{ C ite{ - 770 of G
lu Contr orsCom n a e TeIQ hone
dr ��
Email C' Address 4 - .
Sign a of Own ofltractor /Offcer(s of Corporation License # ,
Insulation Contractor Information
45 /Wri
Insul - Contract any Name &Address_ Telephone
*NOTE: G, neral Contractor must fill out and sign the second page of this application.
Residential Building Application 1 of 2 03/10
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? 1 '''s Yes _ No
5. Do you intend to personally occupy the building forlat 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 au 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 • urre :. •ule
look
AN -,,
-, g Cy re o •wne Contr- ctor /O Icer(s of C. , •ration Date
/ ` Affidavit for W ker's Compensation N.C.G.S. 87 -14
/ The undersigned applicant being t
/ General Contractor Owner Officer /Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s), finn(s) or corporation(s) performing the work
set forth in the permit: - i
_ 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 hastheir 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 Nam
Sign w/Titlee\ I L a't , \a. . , _
W Date: ��
Residential Building Application 2 ci 2 03110