BUILDING _•u.. w ue uuw out oy
Application #
whomever performing work. Must be owner pP
or licensed contractor. Address, company
name & phone must match Information on Harnett County Central Permitting
license. PO Box 65 Ullington, NC 27548
910- 893 -7525 Fax 910-893-2793 www,hamett.orglpermits
Application for Residential Building and Trades Permit •
Owner's Name: Li*
1.
t. . r. Milli s 'III Date: / 01 --12 - la
Site Address: P„ ii ' Wit ate II I , ■ k Its •hone: -'a G•
Directions to job site from Ullington: k e LoY $7 /1) -Ryom Sp r;nq (, e to 1.1 w '/ 23
fumy (2)nN HWYCR7• GD ) m1 (e - tv ka)ver t?, . — Flirt) (1)
onto /Mover . 6:o I 1 /2 rn; Le to or)ra /we 6N /L)
Subdivision: R..-Y"S 1 r) ()Y1 (-{l /1 Lot: D
Description of Proposed Work: Nett) ibm P Ons krw(44?)1 #Bedrooms: 03
Heated SF ,RI-1 7 2 Jnheated SF 111 Finished Rec Room? /VO Crawl Space (v) ( )
Ueneral Contractor Information
BuAd11 g Cont c\ -kcn c , N me 910 - LRM -r)
9 P Y Telephone
I LpJler*ntl n Thiciit 1 C O 1L(- ,li - u
Address License #
n
Must sign & 011 out second page
°nature of Owner /Contrac r /Officer(s) of Corporation
Iectrica Per iitl.for ation
Description of Work .a4s Se Service Size: lik Alt Amps TPale:4 no
3Jep wkpr, Eiertrjr. 9 i oT y� S / -
Electricaj Contractor's Company Name Telephone
57 S 5_ _Cr 2 In a j} 4 papailis 1 P ba, U
Address r License #
Sign of Officer(s) of Corporatio
2-±V AC.
Permit Information
Description of Work — ±VA .
Cort Pieh Ncat - s Ai a1ID- q.SR CX h
Mechanical Contractor's Company Mime Telephone
•, e.S..�ti�.�..• 1•R' � , . A i 1\XC RYfl1Q
` ` s / License #
Signature of Office s) o corporation
Plumbina Permit Information
Description of Work - Pt, tjfl 71 # Baths
Plumbing ontractor's Company Name Telephone phone
cis i L. r • , ti re s. vat vat t.. IS ItI ( n
A -4/1- oga /d t License #
Signature o fftcer(s) of Corporation
Insulation Permit information
Tr_ i 1 r5LtlCticn 1 41 n St- - Fb t A i\\fl
Insulation Cont tor's Company Name & Address CA Telephone
In'> 1 0 — r S.S
Page 1 of 2 3/08
Application #
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 any 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 pbangtid.
Ignature of Owner/ tractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
si 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.
1l 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. ii rear
c. or Name: af�,If•a. T cx t t s wit
Sign w/ 4 . et
Date: Id
Page 2 of 2 3/08