BUILDING Each section below to be filled out Application # Oil 2 5 - 721
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 vnvw.harnett.orglpermits
name & phone must match
Application for Residential Building and Trades Permit
itin Owner's Name: . "l)L 1 is) LQq CI-- Date: /
Site Address: 139 s ..1 ci s tts Cflorh 11∎) Q Phone: 9 to a`P s-7y9
Directions to job site from Lillington:
Subdivision: Lot:
Description of Proposed Work: # of Bedrooms:
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: _ Slab:
General Contractor Information
4n Li,orr
Bui ding Contractor's Company Name Telephone
Addr Email Address
$ gn ure of Owner /Contractor / Officer(s) of Corporation License #
Electrical Contractor Information
Description of Work Service Size: Amps T -Pole: _ Yes _ No
/
Electrical Contractor's Company Name Telephone
Addr: t f) Email Address
rig • : t '= of Owner /Con ra or /Officer(s) of Corporation License #
MechanlcaliHVAC Contractor Information
ription of Work
Mechanical Contra ; ' Company Name Telephone
Address mail Address
Signature of Owner /Contractor /Officer(s) of Corporati• License #
Plumbin • • • ntractor • rmation
Description of Work Baths
Plumbing Contractor's Cos. ii any Name Telephone .
Address Email Address
e nature of Owner /Contractor / Officer(s) of Corporation License #
//- / Insulaton ontra or information
� 4 0 , ' a .r' Srer r
Insulation Contractor'- •a' Name & -tress Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Residential Building Application 1 of 2 08110
`,, Homeowners Applying to Build Their Own Home
Please swer the following questions then see a Permit Technician to determine if you qualify for permit under 1 ers Exemption.
Questio •' -ire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo avai ..e upon request)
1. Do you ow • e land on which this building will be constructed? -- Yes _ No
2. Have you hired or i .- nd to hire an individual to supe end and
manage construction of the • roject? �/ _ Yes _ No
3. Do you intend to directly control• - -• s�onstruction activities? _ Yes _ No
4. Do you intend to schedule, c• - r or dir pay for all phases of
construction work to be don: _ Yes _ No
5. Do you intend to onally occupy the building for at least . onsecutive
months followin• ompletion of construction and do you understan• . if
you do not • - so, it creates the presumption under law that you fraudulently
secure." e permit? _ Yes _ o •
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 changes.
EXPIRED PERMIT FEES - 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is :s r current fee sched e.
1
:Ignature of Owner / to ractor /Officer(s) of Corporation Date
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:
` . J j
Sign wait! -, // � 4 _ _ li:r�_ � . a Date:) �/ 4 ! ) 1j)
Residential Building Application 2 of 2 08 /10