BUILDING Vi
• Each section below to be filled out by Application # I (7 5 2 -5'6 / ; J
whomever performing work. Must be owner Harnett County Central Permitting
or licensed contractor. Address, company PO Box 65 Lillington, NC 27546
name & phone must match information on Telephone Number 910- 893 -7525 www,harnett.org
license. / Ind �� /it pplication'for Building and Trade Permit
Jn 4s
Owner's Name: #ri Date: /2 .5- 10
Address: 6,127 / 27 F Y NC Phone: q lq 894 R1olpD
Directions to job site from Lillington: habaaj 27 East iv Cents Cvnss hun� 5S. L Vio ,41k om IRij
Subdivision: Lot:
� CoDstruction Type: (Please Check) Building Use: (Please Check)
Vew _ Moved House At _ Commercial
_ Renovation _ Addition _ Other _ Modular _ Multi- Family
Total Project Cost: ( gif)f)'0 Description of Proposed Work: 30 X40 &an g to
General Contractor Information J es
Heated SF _Crawl Space () Building Construction Cost $ 1$00!)
Unheated SF ( =Slab (sr Acres Disturbed Stories _ 1
Ginn (iuibler>. LLO 919 524 61
Building Contractor's Company Name Telephone
64 87 N C Z'T Cod' Coco IV, 2 1521 50541
Addr ss �l�tL'CQ/lGf License #
Signature Owner /Contractor /Officer(s) of Corporation — Must sign back of form & workers comp
Electrical Permit Information
Description of Work Electrical Cost $
TS Pole: Yes () No (y Underground (i .Overhead ( )
Permanent Service: Underground (4 Overhead() Service Size: WO Amps
14nme Lar
Electrical Contractor's Company Name Telephone
Address License #
101.4■Cd
naty(e of Officer(s) of Corporation , . .
Mechanical Permit Information
Description of Work IK /A
Number of Units Type System Mechanical Cost $
Mechanical Contractor's Company Name Telephone
Address License #
Signature of Officer(s) of Corporation
Plumbing .Permit Information
Description of Work NJ /4
Number of Baths Plumbing Cost $
' Plumbing Contractor's Company Name . Telephone
1
It('
, ,
wrr Address License #
Signature of Officer(s) of Corporation /
' t.;;- Insulation Permit Information Residential 4d Other ( Q. Not Required; ( )
/hnz ; rnp Stsailhon; . ? ,Yc 919 965' 95 db
_ „ Insulation ntractor's Company Name & Address Telephone
Page 1 of 3 1/07
Application #
Commercial Jobs must fill out this portion
N/A Sprinkler System Information
Sprinkler Contractor's Company Name Contact & Telephone
Address License #
Signature of Officer(s) of Corporation
Fire Alarm System Information
Fire Alarm Contractor's Company Name Contact & Telephone
Address License #
Signature of Officer(s) of Corporation
Driveway Access - NC Department of Transportation Driveway Access /Permit? Yes No
.Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you quality (or permit under Owners Exemption.
Questionnaire per G.S. 87 -14 Regulationsiasto 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 donot do so, it
creates the presumption under law that you fraudulently secured the permit?
_ yes _ no
Sign & date
I hereby certify that I have the authority to make necessary application, that the application is correct
:Z. 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 ilmy changes occur including listed contractors, site plan,
building and trade plans, Environmental Health:permit changes or proposed use changes, I certify it is
+ ' my r onsibility to tify the Harnett County Central Permitting Department of any and all changes.
Atet SF 10
Signature of wner /Contractor/Officer(s) of Corporation tC t
r.
� ..;, Page 2 of 3 1/07
} Application #
Affidavit for Worker's Compensation
N.C.G.S. 87 -14
The undersigned applicant for Building Permit # being the:
t✓ 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 /have three (3) or more employees and has /have obtained workers'
compensation insurance to cover them.
• • Has /have one (1) or more subcontractors(s) and has /have obtained workers'
compensation insurance to cover them.
Has /have one (1) or more subcontractors(s) who has /have their own policy of
workers' compensation insurance covering themselves.
Has /have not 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. // !!
•
Firm Name: 4' /J ac
Sign/Title: /2tMzn anteib
Date: Q ?I." 2O!D
•
•
Page 3 of 3 1/07
HTE# /b
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPEC'T'ION
NAME 27) l~S /D PHONE # SY--5-7y/
ADDRESS 4','--' Z7 i0C 27 ~ 2 /
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT) ~,h7 -7 aN n~ z
PROPERTY LOCATION: STATE ROAD NAME AND # ? 7
PURPOSE OF INSPECTION: o X_ c>
The aforementioned site has been evaluated by the arne County Hea-ftb Department
Environmental Health Section. At the time of inspection, there appeared to be a septic
system serving this site. If this system should malfunction, the owner is responsible for
any necessary repairs.
THIS INSPECTION IS VOID IF:
(1) the intended use of the septic system should change, and/or
(2) the system should fail or malfunction, and/or
(3) the owner or tenant of the property changes, and/or
(4) after six months
BUILDING MUST BE 5' FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
{
of Environmental Health Specialist
2-~3-
Date