DOCUMENTS D9/09/11 Application
Harnett County Central Permitting
PO Box 65 Lillmgton NC 27546
I
Eat section below to be filled out 1 910 893 7525 Fax 910 993 2793 www he-nett orgrpermits
by whomever performing work
Must be owner or licensed
centraaor nooress company Application for Residential Building and Trades Permit
me 6 pnane mull match
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owners Name 6i .Ay/ .0 " LLL Date 1 - /7
Site Address _ .�9 I -S. _!. '.io4' - Phone - C i f—
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Directions to lob site fro Ltlim•lon y.y froili �ii. ._zap-. I „4
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! r eSubdivision --3,4 -) � 6 Lot / 34'
Description of Proposed Work /I/ 5F #of Bedrooms
Heated SF339SUnheated SF 137/.. Finished Bonus Room'+ ..S Crawl Space Slab L—
� / General Contractor Informatidn
LLuMfe ifif /tifz4 LAC . 4/o— O,Q
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Building Cncltractors CompaniName Telephone
P,G U'O4 7Q77 UaMtnit /f C• fl33'� 40-6Sb lcyfi
Address Email Address
694(93 yahoo. CO/2
License #
Elec Ica o tractor Information
11/eder 1-
Description of Work $!tl S/ Service Sizec Amps T-Pole (res No
ice C-( rrL ' '? $ ?4t 5359
Electrical Contractor Company Name /� Telephope
5at, Lisle <71-. i4c.# TL(. /f/4
Address Email Address
I ZCeY7— GC
License #
Mechanical/HVAC
Contractor Information
Description of Work A__ u/- /.. 7654% 62fSr
(f eb /.,26K9
r- I(L/— LLC 4/4— pg O��i
Mechanical Contractors Comp Company am Telephone
-AC. '- k-4'- k-4 /o /7/ " `k //An> 4-("- ,-,?i56? /2_,L7Address Email A dress
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License
License #
Plumbs Co actor Information
Description of Work /1,47a) # Baths
/o✓er 'ntr� gtv /k _vv. 47q— .,57.-.649 516t
Plumbing Contractors om.an//Name p /// Telephone
Address &733Z Email Address
073 fro
License #
Insulation Contr, tar Information
' -/ lig"??z-- 9GCC7
Insulation Contract.rs Company Name & Addres Rd,",
r Telephone
7.09
'NOTE General Contractor must fill out and sign the second page of this application
4
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 that by signing below I have obtained all subcontractors
permission to obtain these permits 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 Hamel County Central Permitting Department of
any and all changes
EXPI ERMIT FEES - 6 Months to 2 years permit re-issue fee is $150 00 After 2 years re-issue fee
s per current fee schedule
/ ' ‘741K7
Signature of O(6fed ontractor/ er(s) of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor Owner �Hicer/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
V 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 suocontractors(s) who has their own policy of workers compensation insurance
covering themselves
Pas 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 workers 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 Na lfr ijA— as C -
sign w/Trtl_ _/ j ._/ Date / i ll,
3� tcj-
List
DO NOT REMOVE!
Details: Appointment of Lien Agent rued en: 1104/2017
Entry 0: 755415 Initially IHsd by: cumberlsndhom.s
Dulgnat.d Lien Agent Project Prop•tty Print & Post
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ypmeMIie %..m Property Type s this image nim yyInnIn phot'[
ex di',Now YOU then file Notice
m Lien Asenl la this project
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