BUILDING •
Application # /9 gra 27 yy
Each section below to be filled out Harnett County Central Permitting
by whomever performing work.
' Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
name 8 phone must match
Application for Residential Building and Trades Permit
r Owners Name: s /{/ 1 7.4., � S � /7f f.' y , Fn Date: / tc 2 0/ 0
Site Address: /Y R aG 3 . Ye t .��r>/is� ea .-P t' /�hUhe: ?fa v/36 Py.3 f
Directions to job site from Lillington: fov t Fr7 /o the i Z 4 7451- ED 0 .v
/P.Ff d fr ✓G v
1
\ , Subdivision: Gt///9 Lot: / J
Description of Proposed Work: �„JX 22 h taw- *JoCF GAreft, C. # of Bedrooms: 7
' Heated SF: Unheated SF: le Finished Bonus Room? 7 Crawl Space: 7 Slab: /ZX 2.- 2
General Contractor Information
Ow,ve.2 ,?..nn,a 12'? 9/o y3l 8f 37
Building Contractor's Company Nam , Telephone
/rn ! • !' rf .�D ,%lrfe/I{ 283RD Prnil,S_ L
Ad • Email Address
'' .l OwA edC
Signature of Owner ' ontractor/Officer(s) of Corporation License #
Electrical Contractor Information
' escdption of Work Service Size: Amps T -Pole: _ Ye No
Elect!: -I Contractor's Company Name Telephone
Address Ema' • ddress
Signature of Ow -r/Contractor/Officer(s) of Corporation License #
Mechanical /HVAC Contractor - ormation
Description of Work
Mechanical Contractor's C• • pany Name Telephone
Address • Email Address
Signature of Owner /Contractor /Office • . of Corporation License #
PI . binq Contractor Information
Description of Work # Baths
Plumbing Contractors a •mpany Name Telephone
Address Email Address
Signatur- .f Owner /Contractor /Officer(s) of Corporation License #
Insulation Contractor Infor • ation
sulation Contractor's Company Name & Address lephone
*NOTE: General Contractor must fill out and sign the second page • this application.
Residential Building Application 1 of 2 10/10
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 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 ariv 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 Hamett County Central Permitting Department of
any and all changes.
EXPIRED • ' IT FEES - 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is a o -r curr: fee schedule.
7a-Cr ZO /n
ignature of Own- lC actor /Officer(s) of Corporation Date
Affidavit for Wor is Compensation N.C.G.S. 87 -14
The undersigned applicant being t e:
General Contractor Owner Officer /Agent of the Contractor or Owner
Do hereby confirm under penalties of p 'ury 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 :me:
Sign w /Title: d '
' Date: /nd
Residential Building Application 2 oft With