BUILDING • Each section below to be filled out Application # lo
by whomever performing work. Hamett County Central Permitting
Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910-893-7525 Fax 910-893-2793 www.harnett.org /permits
name 8 phone must match
/ Application for Residential Building and Trades Permit
Owner's Name: /-(T in2cR a gi SfaY1 Date: lv- 2 -to
Site Address: Phone: qlq- 4441-SG 5V
Directions to job site from Lillington:
Subdivision: 67.2.F#1 oat /c S Lot -3
Description of Proposed Work: # of Bedrooms:
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: _ Slab:
General Contractor Information
7Ary l goL'insor. 140r4.e5 q10-q11 -25ln
Building Contractors Company Name Telephone
5J di 1 I \(nYNSP g t. 4-e 3o0 _ ricobin5on, konAtS, 4 L 00. c
Aj(l �/ r .. Email Address lJ 1
Signatt of Owner/Contractor/Officer(s) of Corporation License #
Electrical Contractor Information
Description ofWork Nt'-t4 Co✓r s �r,.eh/n.. Service Size: Zoo Amps T -Pole: 'Yes No
5 24 r 61,cdr ;c 'bp- U3- 2.413-5:3 Elec !J trical 6ontrac is Compan y Name Telephone
1 Iki k1 pp
,tacQ tcl. 6m - lea :l •
Add ess Email Address
an, ' ( 1000(? u
ignature of ner /Contractor /Officer(s) of Corporation L icense #
MechanicallHVAC Contractor Information
Description of Work r e w (DA i fru ail or
All rircw..J. healrwi a- 4Jr 9 0 -7 I 4 4 -
Mechanical Contractor's Corilpany Name Telepho
9015 O Irk ( 1'e. v1}eL Qo ;Il
Addre$s 1 Email Address
2919 Z N Clnsc I
it AU
S ignature of Owner /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work Not-) Co r,S }rH cI ,9., # Baths /' �
De II I) �j t fILAW% h linqq cm-RIR -4 p
Plumbing Contractor's Comparfy Name Telephone
71. I Doowa+rnl r r Dr. / F P 7 o4IeQ; l li I Nit 2f1 30(o Email Address
ss ,x- 2 �i - 209 F )
Signature of Owner /Contractor /Officer(s) of Corporation License #
rr''
Insulation Contractor Information
Tri• &; IOPin PrettAr h 9 117 " 231 -or-I S7
Insulation C C ompany Name & 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 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? _ 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 Hamett County Central Permitting Department of
any and all changes.
EXPI D PERMIT F 1- 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is as er curren fee -, .4ule.
— /U -/4 /0
Signature Owner /C • ntractor /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:
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. y .
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.
Company or Na e: d'79 - 2C �s� ,44»!S 5
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Sign w /Title: i" sett— Date: / / y —/0