BUILDING 09109111 Application#
Harnett County Central Permitting
PO Box 65 Lillmgton NC 27546
Each section below to be tilled out 910 893 7525 Fax 910 893 2783 www harnett orglpermits
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match II 1--6
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Owners Name IEA ArP -l1 Ay Date 3- 3G- ( ,
Site Address 54V LEE (t ^� �4 rile gA 6tMAa)41 AV-Phone 4/4-- 2S2— 2S3g
Directions to job site from Lillington1 ke- '4t/ -NII � rowan Rroep-A�w\ gN '�� (3 pc,IeS�
osc Uernest S} -r6tn}p LFR �@411h Lt6 ha) (n-f- i5 Y2 ,tole
Subdivision Lot
Description of Proposed Work Q'J it 419 #of Bedrooms
Heated SF 20I2- Unheated SF 412O Finished Bonus Room? /I0 Crawl Space V Slab
General Contractor Information
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Building Contractors Company Name Telephone
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Address Email Address
I1590
License#
Electrical Contractor Information
Description of Work 0);C C Ne..J H*44 iP Service Size 2/0 Amps T-Pole t--Yes_No
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Electrical Contractor&Company Name Telephone
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Address Email-t-rdca i43Cefrch-ao#
Mechanical/HVAC Contractor Information
Description of Work H MV') A.e'
Jt'FN Mc* t-A 4- kr 7i C- 10-5q7 -565 I
Mechanical Contractor&Company Name - Telephone
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Address Enail Address
Inl#
License#
� pppp���� Plumbing Contractor Information
ft of Work � fruit.) k11 SJ #Baths
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Plumbing Contractors Compan Name Telephone
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Address I Email Address
ICRAt
License#
Insulation Contractor Information
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Insulation Contractors Company Name &Address t Telephone
'NOTE General Contractor must fill out and sign the second page of this application
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 sinnmo below I have obtained all subcontractors
permission to obtain these permits and if my 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 PERM.-FEES-6 Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is as surretit feschedule
3-30- I/
Signlature of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation NC G S 87-14
The undersigned applicant being the
General Contractor Owner V Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) hrm(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/
V 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 pnor
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 RCEP r` (DP italn TitG
Sign w/Title -L-54773v y Date 3-36'. 11