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BUILDING Application # /✓ 5 77 1 ,- 257/9 'Each section below to be filled out by whomever performing work. Harnett County Central Permitting Must be owner or licensed PO Box 65 Lillington, NC 27546 contractor. Address, company 910- 893 -7525 Fax 910 - 893 -2793 www.harned.org /permits name 8 phone must match Application for Residential Building and Trades Permit Owner's Name: Dan 3ar e r Date: I la 21 ' I O Site Address: LAA1 C(rcAE_ Fugval Var ;nw pc 27524. Phone: S5 - 360 Directions to job site from Lillington: L2avt IrAwsea;on o{ ZI O r L \ j yo n or aoe. 3 w.. \es award5 hi v a . q VAA A,. +ufr. r ;o\,� ov.\n loAkarok 1 90 geer Yit v...;. Alan ri5‘1k an� �DA•e■ /�texecnal-V 1 � 1 +a 7 Oh P v7� Cinie ,na � Subdivision: \\arot L)orS / f Lot: Description of Proposed Work: Dear C7aaA / .51,o # of Bedrooms: 0 Heated SF: Unheated SF: S76 Finished Bonus Room? N 0 Crawl Space: _ Slab: General Contractor Information ` 10.4. &v,s Coin kr „�kI Rlq• L'122. 306:7 Building Contractor's Company Name C e Telephon 1f1 Sent LA# „{9elny PC. 2Wi2 oncts�h \ackman Ad ss, 1 Email Address S7 £t2— Signature o wner /Contractor / Officer(s) of Corporation License # Electrical Contractor Information // Description of Work Lane. olelowl•..A 9 v'- a Service Size: 100 Amps T -Pole: _Yes ✓No ^ aa...lsorj Elec.{y;c 201 - 32'-1 Electrical Contractor's Company Name Telephone 375' -{ C 4.51:. 12oA• �v.. Via 2lfU Ad ress Email Address 3/.•w.o 37 5 Lj Signature of Owner/Contractor/Officer(s) of Corporation License # Mechanical /HVAC Contractor Information Riess'•'• of Work Mechanical Contractor's Company Name Telephone Address Email Address Si. s - • e of Owner /Contractor /Officer(s) of Corporation License # Plumbin g Contractor Information Description of Work "Roil ola P r , 1 rrosa bib # Baths 0 w..A,.. ' NV VW% 370 • t q S'6 Plumbing Contractor's Company Name Telephone 74L° sa 1 V TAN ) . Sea Arc ti sect Addre _,t,� 1 Email Address d�a�L 305 1 Signature of Owner /Contractor /Officer(s) of Corporation License # Insulation Contractor Information Ptsu1a}irj Inc_ Plea Fn 1244 , e Re,1 ;,ti, 772. -9 Insulation Contractor's Company Name & Address Telephone *NOTE: General Contractor must fill out and sign the second page of this application. Residential Building Application 1 et 2 08/10 Homeowners Applying to Build Their Own Home Please answer the following questions then see a Permit Technician to determine if you qualify for permit under Owners Exemption. Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo available upon request) 1. Do you own the land on which this building will be constructed? _ Yes No 2. Have you hired or intend to hire an individual to superintend and manage construction of the project?. . _ Yes _ No 3. Do you intend to directly control & supervise construction activities? _ Yes _ No 4. Do you intend to schedule, contract, or directly pay for all phases of construction work to be done? Yes No 5. Do you intend to personally occupy the building for at least 12 consecutive months following completion of construction and do you understand that if you do not do so, it creates the presumption under law that you fraudulently secured the permit? — Yes _ No I hereby certify that .l 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 a y 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 as er current fee schedule. l ( Signature of Owner /Contractor /Officer(s) of Corporation Date ti Affidavit for Worker's Compensation N.C.G.S. 87 -14 The undersigned applicant being the: 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. 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: 31c lthQil S %� v/1� p r 11 Sign w/T �JlLy LJL /* L twCX ��� t�r�117 1is+^ Date: Residential F3uildi nq Application 2 of 2 03/10