BUILDING Wean*
War moon ben mot b. Mud out by Hamad County CmPenning -
ran Y porlanaing du work. U.S be pe Ba a6takrgm,NC UM
tear or b...0 ph e..ar. nisch 0109634575 FO 010a13a7a6.eeaeswt .. nb
loball onS I pent mus
pba.dMmdaborne ariereals
Owns's Name: P.'nan It td 1.4..f V ink% _ Deem 0 1 7
8b Mdlsse Phan -(r
Dinka,to lob its from tAanglon: kl'Gp t.rat r arfue Br 4.
=rY_ ,Mt It/.4 I1 a -re r.rtYtr r- nr1-T .F.
Led-.. g*ff ..stfr v4
Subdivision: Lot
D esanon ofProposed Wan:{\hal ctenet tr lnl 926111 ttel ldi..te
Heald BF Unhand BF • Mining cat a IILVo1000
OCIC of oulhr Co6�tln.dSe. . It. aSa.Ans-SISS-
B uldMg Co,Mraola's pant Noma Telephone
PlaS a Withal Ave • si \i4te.eiCdnl4 diatt tong
s 1.41.lse•out
nid
-.,, i .. ...„, .... 171,. I., ,, Ent**Costa 1,11ovo
pe.oi aen of Watt .-1• t Bevin Sae: s 1r-
?%.otras flteak ;52.531.3484
calm Contactors Company Name TaluPhaha
QBY 1ldbl wtatHnuti,ac Mit tome len t eviae.l.r1'
Addressagwt-u.
Signature aown.dkalinILISO.n0filenal CorporSleI,J..alat
iS .MedunloalCoa fe22
Deesdp6ondWont PH*l Hunks
Silt MiOnthi a a ca Z3nwoas
add sinal C��ontradoes Company Name Tiers.
lab i Q/�7ad rat tad 1►ittSt04• hM 3n1AS Q1QMUspaaapidere ina.
Address Emil Anna,
al 63
SgnaWn of Or9ra0CantaaaCOMseRa)of Cowman
n re
rinfarr r : Pt nbing Coaa 7.f4DD
Dnaptbn await Y Baha
11 re Met twit(91t,pyl.3� a sasz.+-3aav
Plumbing Calbaobrs Company Nd9v Tonga
7bd6ost. LVya Gticlara, 20/S30 ress Email A_w een.
14ne ;
tQtaairs of Own.nCantamoOaleats)of Cama ten Lions N
illninaargenithill
Lta.,Ftr...t tarn u..w- -nriJ-rn&arc 7.ci to3-rtr
MWaaon Conaaaets Canpany Name&Address Tdepbese
1NOTB:Oat .J Contactor mud MI out and sign ths second page of this application
I Ai„I1,Nr,,fi40Q,41•bl'k:dig., 1N9 .^-El
SofolOr Contractor Informador!
SprinklerC actor's Company Name Telephone
Address Email Address
Signature of Officer(s)of Corporation License#
�``�/7/ Flre Alarm Contractor lnformato8
Fire Alar C6ntractcvs Company Name Telephone
Address Email Address
Signature of Officer(s)of Corporation License#
Arirewav Acres- 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 Hamett County Zoning Ordinance. I state the information on the above
contractors s correct as known to me and lgpy changes occur including listed contractors, site plan,
number of bedrooms,building and trade plans,Environmental Health peril changes a proposed use
charges, I certify It is my responsibility to notify the Hamed County Central Pennidtrrg Department of
any and al changes.
Expired Permit Fen-8 months b 2 years permit re-issue fee Is$150.00. After 2 years re-issue fee
is charged at full price per current fee schedule.
,Ls ii(o/,
„Sighliture Owner/Contractor r( of Corporation D
Affidavit for Workers Compensation N.C.G.S.87-14
Theundersigned applicant being the:
Genera Contractor _Owner _Officer/Agent of the Contractor or Owner
Do hereby confirm under pennies of perjury that the person(s),firm(s)or corporation(s)performing the work
set forth in the permit:
Has three(9)or more employees and has obtained workers'compensation Insurance to cover them.
Has one(1)or more subcontractas(s)and has obtained worker;compensation insurance to cover
theory
Hs 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 winch this permit Is sought it is understood that the Central Permmmg
Department issuing the permit may require certificates of coverage of waker'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 wait.
Company or Name: i f G _ t - o.::- [[sass
Sign wails: ' Date: -
/ 4-