BUILDING •
Application # 4.—°1 Z 4 /e 5- 2
'Each section below must be filled out by Harnett County Central Permitting
whoever is performing the work. Must be y
owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546
company name & phone must match 910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
information on state license. COMMERCIAL
Application for Building and Trades Permit
Owner's Name: Date: /0 ( /U
Site Address: ( raeOL., L Phone: /.
91 / C e 13 S er
Directions to job site from Lillington: 27 (do e-a--}- '4-r> ./13, , .Fu:. / c.
�f m1<< en �ert 04 o.c.rrll. /c4.-.. �� tCA e.-''Sm
Subdivision: ttt�o ti lc ke - Lot:
Description of Proposed Work: — tear% tt G<. -• 1 E. ol A .
Heated SF A Y/4_ Unheated SF t ZC7
General Contractor Information: Building Cost $ 30 - 6
541 l�r e t 1 9 5 3 S e l t c C C I
Building Contractor's Company Name C ! / Telephone /
e-/Ce *ers. - R4 Sc.. 'cr !' /VC ?n "r � t.6 1Vt G_. oi(JC.. &cfl oJ
Address Email Address
Signature of Owner/ • - •r /Offcer(s • orporation License #
Electrical Contractor Information: Electrical Cost $
Description of Work Service Size: // Amps #T -Poles
Electrical Contractor's Co •any Name Tel(phone
Address mail Address
Signature of Owner /Contractor /Office . s) of Corporation License #
Mechanical Contr: tor Information: Mechanical Cost $
Description of Work # Units
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature of Owner/Contractor/Officer(s) of Corporati• License #
Plumbing Contractor Informat • n: P • mbing Cost $
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
Signature of Owner/Contractor/Officer(s of Corporation Lic- , se #
Insulation Contractor information
Insulation Contractor's Company Name & Address Telephone
*NOTE: General Contractor must fill out and sign the second page of this application
Commercial Building Application 1 of 2 OB110
Sprinkler Contractor Information
Sprinkler Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Fire Alarm Contractor Information
Fire Alarm Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Driveway Access - NC Department of Transportation Driveway Access /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. 1 state the information on the above
contractors is correct as known to me and if ray 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 charged at full price per current fee schedule.
/ / ( io .
Signa ure of Contractor/Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
�� be
General 6M
ontractor 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:
Hnd ' compensation insurance to cover them.
Has as one three (1) (3) or or more more subcontractor a s(s) has and has obtained obtained workers workers' compensation insurance to cover
em.
A 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. c
Company or Name: Mc in t ir. r ++
Sign w /Title: i� _______....ea .t . r Lc 4 Date: j I rir / n
Cominercial Building Application 2 of 2 08/10