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08/08/11 Application#
Harnett County Central Permitting
Eaoh,aecoon below
b M teed out PO Box 65 Langton NC 27816
by wt omeyar Deaoto nark 910 ee3 7826 Fax ow e93 2793 www Mmett orgpennits
Must be owner or honed
contractor Adtl1e6s company Implication for Residential Building and Trades Permit
name 8 phone must match ?—/ /
Owners Name gf'� lyI/�,�jAi.fru. Date p?-/9/7
Site Address 3,27 f•/`l Trr/ erre LI/Vern ,/C ,2"13.y^ . Phone 9/0- 890-sa025.-
Daectons to job site from Lillington "/o lough -Attn., bre'? err £70 #A64 ib<„fi H.n
f71 02/44,://f ' t.F-,,,^n /:541-1 dive tioY on r�/ /]Once on /P
/ O
{ driveway ,c /n1-,9 )
Subdivision Lot
Description of Proposed Work //1ein I bi0rn 14/5 Q/t-A ' 046 Mhe^4"•#of Bedrooms
Heated SF Z( Unheated SF Finished Bonus Room'_Crawl Space _Slab
General Contractor Information
leA 64e60AV 6'e-;Alfas 9/0• PdY - 4r3a
Building Contractors Company Name Telephone
/9//d /1/C Z7 cd 4l/:, .1.,, A2.474/tniscyAr//ceOjay�L Cent'
Address Email Add ss
75' 73-7
License#
)=lectncal Contractor Information
Description of Work OcJnir Service Size _Amps T-Pole _Yes_No
Electrical Contractors Company Name Telephone '
Address Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work
Mechanical Contractors Company Name Telephone
Address Email Address
License#
lumbma Contractor Information
Description of Work � #Baths
Plu bang Conr s Company Name - Telephone
Add .;s Email Address
License#
Insulation Contractor Information
Insulation Contractors Company Name 8 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 concoction will conform to the regulations in the Building Electrical Plumbing and
Mechanical codes and the Hamed County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that by elinin below I have obtained all subcontractors
permission to obtain these permits and if pay changes occur including listed contractors site plan
number of bedrooms budding and trade plans Environmental Health permit changes or proposed use
changes I certify itis my responsibility to notify the Hamed County Central Permitting Department of
any and all changes
EXPIRED PERMIT FEES-a Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is per current fee schedule
List 1.124,---- a 7y77
,85 lure of;.3 /Contractor/Officer(s)of Corporation Date
l Affidavit for Worker's Compensation NC GS 87-14
The undersigned applicant being the
General Contractor _Owner Ofllcer/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
setfonh late 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
covenng themselves
✓Has no more than two(2)employees and no subcontractors
While working on the protect for winch this permit is sought itis understood that the Central Permitting
Department issuing the permit may requre certificates of coverage of workers compensation insurance poor
to issuance of the permit and at any time during the permitted work from any person firm or corporation
carrying out t work
Compan or Na / S . 4 rtosiw?• e'uy Y
Sign winds etff4f7 rte7... r�i e —/ 7
Amar