DOCUMENTS / OFFER TO PURCHASE 09!09111 Application#
Harnett County Central Permitting 11 -Sal) 44101 I
Each section below to be tilled out PO Box 65 Lillington NC 27546
910 893 7525 Fax 910 993 2793 www harnott orgrperm its
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match
Owners Name peen 't' l44nnak�Lois
Date /0'20'/7
Site Address L2 4b Ma Lois An5,t3C Phone 9/9- I S' '/8 7(.
Directions to job site from Lillington
Subdivision A Lot
Description of Proposed Work Ne� 5 F D #of Bedroom,
Heated SF ZOOS' Unheated SF 674 Finished Bonus Room /JO Crawl Space V Slab
l ii General Contractor Information p
f(tt40M Co, c rni,6% .y KL I/o- gin- /a /
Building Contractors Company Name Telephone
Pa Bax WS 'Dunn NC 2i(33r /44rt/ecrui/.reoashug fin. t
Address Email Address
(Is9y
License#
Electrical Contractor Information ✓
Description of Work 14‘2 PM.) He*St Service Size IX/ Amps T-Pole Yes No
14.sorI 1t Pepe 6(ecti':C41 (fntreat/vs 9r9- 1126-OK37
Electrical Contractors Company Name Telephone
SI $e Alt( Crete Pr. Puna NC in75til rL,p&rely e-.•IhelAe.c/-cnM
Address Email Address
2la 4 - u
License#
Mechanical/HVAC Contractor Information
Description of Work Ne to Hr r-t
Bt4ltlac.t;r rCntd,l-inC- L& AIL tanCaM-kr (9/5- 4-5-7-922-3
Mechanical Codtractors Company Name Telephone
fab 5 Fa6.A-1 hie F ,N. I r4rire, N L
Address Email Address
License#�y
plumbing Contractor Information
Description of Work (Lieu) t-01154.- planb)-4-f #Baths 2-
Cdbe/t P14Mb, hc Ca Inc I `I10-56 --63o 1
• Plumbing Contractors Company Name Telephone
141 1-0A-0TH # 'D„n,1 EJC 1834 1P & t`atvsl-4i. Aa
Address EThail Address
License#
Insulation Contractor Information
Znsitkfi S ?nc 5162- Fijelkii'k 4 g414,5r, qiq - ?7z- Mood
Insulation Contuactors Company Name S Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
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 tome and that pv sianma below I have obtained all subcontractors
permission to obtain these permits and if gay 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 as per trent fee schedule
fin il Gt f be- to , ?
Signatureof Owner/ ntractor/Officer(s)of Corporation Dale
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor Owner I/ 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 fort in the permit
fort
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 workers 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 1�
Company or Name Retied flt� Cow-c*'t cT/YJ� :T b1 C
Sign w/Title 4' i1 /1 1 ' f /C5/Ma{,✓t-j M.I/ Date /G-i0', 7