BUILDING 'Each section below must be filled out by Application # / 579 257 7
whoever is perforating the work. Must be Harnett County Central Permitting
owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546
company name & phone must match 910-893 -7525 Fax 910 -893 -2793 www .hamett.org /permits
information on state license. COMMERCIAL
Application for Building and Trades Permit
Owner's Name: (en1e 0teo( F/ele/n,s Date: it- 7- 10
Site Address: ICU Ne Town )€04) (taeton,lUC .2 83.6 Phone: 919-Y99-
Directions to job site from Lillington: Huey .. 4 .7As1envoile fo )Y-J? rain e
con-h e .27 40,r1 3-3 ..•,Y er �"kbr TWel rocl fain /fit ,jaIs "{c
c eQrr en.1 owl etc iol. r ww A
Subdivision: Lot:
Description of Proposed Work: opn /raA Sr s At /fer
Heated SF Unheated SF 4 . SO f¢'
/ General Contras or Information` Building Cost $ la 400 0.00
.S4A /We'd burl , eJ [GC Q/9- '1'76 - -) 6.13
Building Contractor's Company Name Telephone
/9 Tro,nwar Roae4 Sva1 Ale .27330 sat to,Jnfait/,6.u,64J e', ea4;l.co,n
Address /Lazes/ Email Address
67035
Signature Owner/Contractor/Officer(s) of Corporation License #
Electrical Contractor Information: Electrical Cost $
Description of Work Service Size: Amps #T -Poles _
Electrical Contractor's Company Name Telephone
Address Email Address •
Signature of Owner /Contractor /Officer(s) of Corporation License .#
Mechanical Contractor Information: Mechanical Cost $
Description of Work # Units
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature of Owner /Contractor / Officer(s) of Corporation License #
Plumbing Contractor Information: Plumbing Cost $ .
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
Signature of Owner /Contractor / Officer(s) of Corporation License #
Insulation Contractor Information
Insulation Contractor's Company Name & Address Telephone
'NOTE: General Contractor must fill out and sign the second page of this application
Commercial Building Application 1 of 2 3110
/arinkler Contractor Information
Sprinkler Contractors Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Fire Alarm Contractor Information
Fire Alarm Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Driveway Access - NC Department of Transportation Driveway Access/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 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 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 charged at full price per current fee schedule.
l /
Signature of OwnegContractor / Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
nd
✓ 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 i 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.
+/ 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 Name: . Sgn lro� A p i.� , , 7j, LLC
Sign w /Title: 1 / i es.;4f"f' Date: //- t-/ D
•
Commercial f3u lding Application 2 of 2