DOCUMENTS 09109/11 Application#
Harnett County Central Permitting 11-5- .575.E
Each section below to be Plied outPO Sox 85 lilangton NC 27548
by whomever pantomime work 910 893 7525 Fax 910 893 2793 www hamett orglpemira
Must be owner or licensed '
cani2&or Admancompany Application for Residential Bulldino and Trades Pen
name a phone mustust match E
Owners Name A1O 5 TYfv,vnR-L Date 7-4961- ?or?
Site Address ERrUEbT W,n,p,vq) )Zp Liama,Tnn) Phone
Directions to lob site from Lilington ikin_5 27 WEST 7ie4T oYUT() l P litiE3T honws/
')fy3 n>V T2hL4I
Subdivision Nye Lot
Description of Proposed Work a 5/N6L7.' (#9/1911 v1 17444E' #of Bedrooms 4
Heated SF 29W) Unheated SF 2036, Finished Bonus Room9 NO Crawl Space yes Slab _
General Contractor Information
ctrl m. awnrNrn (netw447 CC). /AP 9191729. 49.3
Building Contractors Company Name - Telephone
-n PY,x /4c ,'c -mm
Address Email Address
head,
License#
Co or Information
Description of Work 7✓ke-) J Service Size _Amps T-Pole ✓Yes_No
ZWEE1 aal7711 ys - 919- 999- 7767
Electrical Contractors Company Name Telephone
Addressk) NEIL TlittnIkS 7 /,IImtt,-e1t)
213 Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work 411k) NIA L Gj/STE,'✓,
C4Rrn_)r114 1119io 947 7707
Mechanical Contractors Company Name Telephone
37.20 rr5 /5- sol C41t=ryj4a
Address Email Address
23549
License#
Plumbina Contractor Information
Description of Work DLUM&a/b #Baths
ln/Abtu Y2 Rump,nn, - Srz UighniPYv 9E0801n ZZ4q
Plumbing Contractor s Company Name Telephone
5555 `r)177}(})Q h7 _
Address Email Address
-1574
License#
Insulation Contractor Information
?RI CITE 9)0-486-8E355
Insulation Contractorcompany Name 8 Address Telephone
'NOTE General Contractor must fill out and sign the second page of this application
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 Hamett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that by slams,below I have obtained all subcontractors
permission to obtain these osrmita and if gm changes occur including listed contractors site plan
number of •_•rooms • - •ing and trade plans Environmental Health permit changes or proposed use
changes = dy it r y esponsibility to notify the Harnett County Central Permitting Department of
any an. -Ile :noes
EXPI D P •MIT EES• c Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is •aY .tf-• ached le
as •
le/
7-1 It
v"rd•r/Contractor/Officer(s)of Corporation Date
•
Afh• vlt for Worker's Compensation N C G $ 87-14
The undersigned •••hca . =mg the
V/ 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
`I 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 workers compensation insurance prior
to issuance of the permit and at any time dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name Av., _ dv ,, (2/x.6-77C, /,e
Sign ...wadegi � Date 7" LTL- 7017
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