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BUILDING Application ti /0 Sao 2- n YRse. SUCIKS1 t 10 be (Nati mit Har heeever nett County Central Permitting tt worming work, "0 box 65 tillington NC 27546 atypic ii carsec 001 E01 cotes 910-893-7535 Fax 919803 M -23 www.hamen otgypenNts r. ,:t, company naive & shone MUST -/c2 /9/11724 &rot Application for Residential Building and Trades Permit Owner's Name: Wynn Consign:3,50li, inc. Date: _ Site Address: * Penes dor-. Ptione:9/9 6e3-79‘ Directions to job site from Lil eltelf 27 2' s7 /et - 7 - cite Rae e he 4 ats 20,?' et cAl aokeravgi AAM s 0 /re it Ad kte r Subdivisron i7uera ati ,&N e-S, Lot: , Scat- 7.5 - Description of Proposed Work: New WeNtimen # of Bedrooms: 3 Heated SF M2 ' • Inheated SF to/ t i c sloshed Bonus Room 7 Stawl Space: V SI b a _ General Contractor Information Wynn Construction. Inc 919 603 Building Contractor's Company Name Telephone 25; capitol Dr. Cruetirrincm NC 27522 edwartl©wvynnconstrud.com ATtstiess 4- ,4 I Email Address „ 46295 Signature of Owner/Contractor/Officer(s) of Corporation License # Electrical Contractor Information Description of Work New Construction Service Size: 200 Amps T-Roiel Yes No R. A. Jackson 919 730-1251 Electrical Contractor's Company Name Telephone 9261 Raleigh Road Synnim NC 27504 Address t Email Address t cr N ; 2114 Signattkre of Owner/Contractor/Officer(s) of Corporation License # MechanicaUFIVAC Contractor Information Description of Work New Consliliction Stegnensun HVAC 919 329 0686 Mecnanical Contractor's Company Name Telephone 343 Shipwash Dr. (3amer, PC 27529 itderesc' Email Address Fwwiel - — 18644 Signatutof Ownef/Contractor/Officerls) of Corporation License # Plumbing Contractor Information Description of Work New Construc # Baths - Morton's Plumbing 919 669-8655 Plumbing Contractor's Comoany Name Telephone 3150-A Omar Rd Clayton NO Address Email Address Ntr 22152 Signataie of Owner/ContractorrOfficer fp) of Col poi ation License 4 1 Insulation Contractor Information Tatum Insulation 919 661-0999 Insulation Contractor's Company Name 8 Address Telephone *NOTE: General Contractor trust fill out and sign the second page of this application. Homeowners Applying to Buiid 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 au 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 a r curren ee schedule. i ig ature of Owner /Contractor /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: 1 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: Wynn Construction. Inc. Sign waffle: t d Date: /2-4,--/0