DOCUMENTS 09/09111 nppuucami if
Harnett County Central Permitting /7320 V/e923
PO Box 88 Lillington NC 27548
Each section below to be filled out 810 893 7525 Fax 810 893 2783 www hornet(orglpermte
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 8 phone must match
Owners Name Wirt. Q D&S4 1t m1 ( SuC• Date S-17
Site Address 751 AJC/y YL.✓dDr Phone 9e603-MS-
Directions to Job site from Lillington Rem Beet n 1ltit o 2..10 awil 3ar les Leff eN 40/ lef
for ISe11r1/21 Leiou 0-hallhea4t. Ed Cor YR sae , Ala" Paoli ndleft.
Subdivision Alexi Padd /r Lot
Description of Proposed Work Aleut Lo✓SfraiC7I4✓ ' SIO #of Bedrooms --JJ'F--
Healed SF 2/617 Unheated SF-Sal- Finished Bonus Room9 Al Crawl Space A Slab , _
General Contractor Information
big„A C_trtc4lrttet:.aPus. 919 /003 . 776 S
Builth g Contractors Company Maine Telephone
2s3o OA P4 I P•. S/e /os&atssq/ft 27322 eladrie4/404hesea.esst
Address Email Address //
ybz9S
License#
••/I__ 11 Ea�err,ttical Contractor Information
Description of Work /Ingres 'oareetiON Service Size JZ00 Amps T-Pole _Yes_No
Q. ft. 5aek4oel C/et h•'C. 9/9' 730-/Zs/
Electrical Contractors Company Name Telephone
92.101 61601. toort,NQ 276-Dv
Address 1 I3aEmail Address
zitIL/
License#
echanical/tiVAC Contractor Information
Description of Work Neu., rare ell
Pert:Usti- kat asd. f1:r 9/0 gn-tdo0
Mechanical�� Contractor/s�Company Name �/� /� Telephone
772310,fetAkek• Asbe3 -t 6!.3.5 r
Address Email Address
/10200212 /13 boss!
License#
plumb ng Contractor Information
Description of Work viol #Baths .2. ,S
ga ins hip 9/9.st0. 033
Plumbing Contractors Company�J4.Jarhe Telephone
3/44-4 OA2rPl. elayfed Alt Zing?
Address Email Address
alsz,
License #
Insulation Contractor Information 9/? 100-0729
774M .�A/SQbliO4/
Insulation Contractors Company Name &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 Harnett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that pv swine 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 Harnett County Central Permitting Department of
any and all changes
EXPIRE• PERMIT S-6 Mon s to 2 years permi e-issue fee is$160 00 After 2 years re-issue fee
is as p= Curren a edule
S—/2
F=tura of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor _Owner V.OfficerlAgent 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
VITias 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
Hae 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 during the permitted work from any person firm or corporation
carrying out the work
Company or Nam /11/ a daS71r*ts rO.✓
/�_1NC-.
Sign winds "��^�' G/ r- 1/4W. '. -' Date_ S/2 _
DO NOT REMOVE]
Details: Appointment of Lien Agent Initd ially ion: ae12017 nmm�2
Entry it 620474 - -
Oezl Orraletl Llan Agent I
project Property Print B Post
y 'iy Pond mEelrlcnitlot 067 ID,Imnron Tillelnrvnnm Company 160 every pond dr.
Lne. - Ngyay taro,NC 2IR6 D a
nn Ni
Ie W.Hugel' 5 1071 Selvign NC bamtll Cm:nry
Con:rntlorc
filn 9c{ 1 Nesse lost W i e notice no the lob Sire
flume.FA -figs Property Type Sapplion nee Sabra m rooms:
I... ).ven.41 seam Dm image with you:mart phone to
em.ih L view this filing.vmmomben rile a Notice
D2 Family Dwelling to Den Agent for this project.
owner Information
„yt Iioto I
2550 opilol m.
meeymm5 NC 9522
United Stater
Duel/9e94yANY(19479.46om
Phone:919-522-1342
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