BUILDING 'Each section below to be fined out by Application # /✓ 5 9P 2 7 2 7
whomever performing work Must be owner
• or 9cenaed contractor. •Address, company
name & phone must match Information on Harnett County Central Permitting
license. PO Box 85 IJllington, NC 27548
Phone 910 - 893 -7525 Fax 91 5.893 -2793 www.hamett.org
Application fo•Resldentlal Buildlna and Trades Permit
Owners Name Il• Ct oek.laa An QS r:e 4 e v: L( Date: /z-/l r/r o
Site Address:_ 34 3 / Cat, dry Phonel! (4,1( - 4S
Directions to jab site from IJllington:
Rt.27 towards Rt87. Tun lett on Tingen Read. Tum left into Subdivision on Strike Eagle Drive.
71,. /eAt 3v• ke.bvsic_f, 4 s— itt a- : j c�Vc,�., - i o.. lel/
Subdivision: OAAene Qo jet' L ot: / 7
Description of Proposed Work: S i vie 1. ( 1 1 if, #Bedrooms: .3
Heated SF / 9 /�/ Unheated SF 1/0 FInIsheY'Rec Room? Vc4 Crawl
General Contractor Information Space
'; II CIAlk �a..ta£g'FIs cu:)(, I- (9 10) ( 40 1 -‘, -.P-8 S t � A b d3
Building Contractor's Company Name Telephone -
L inn lue4vtAtt lfl ,; G„-lea. s., ;4r a,10 Pe.� 4twil. NCou3fy 3f- IS9 -Q-BL - U
Add s s License #
tvl "a " Must sign & fill out second page
Signs a of Owtp6o Officers) of Corporation
Electrical Permit information
Description of Work bJ..... £tc ,.,, '"r Service Size: Zoo Amps TPoI:C no
Sa e Flrr- lc.�c� 0110)3 —A
Efectriatg Co r ctor's Company Name Telephone
4sy Wlr 4 end. 4ate+1••tcutlIt tuc al- 83j), lobo („-u
Address
CaVithitt\ License #
Signature of Office of Corporation
Mechanical Permit information
Description of Work /J••., Wes-4- 4 tom(`
6
1 1 1 RB - VC - A \(i 1 6nc-. ( 4%Cy ( ,s
Mechanical Contractor's company Name Telephone
sat - 7-403 ot,tt,i tk cyti- kuRlt,nxat3oy 1587'
Address p ,', License #
Signature of oer(s) of Corporation
plumbing Permit Information
Description of Work i✓�..� PA. /,.� # Baths d / /Z
- '1/F9/4N- i�,uCw PiaenefiV6 ei, -9 ' €%'4
Plumbing Contractors Company Name Telephone
3a M.° corn f'n DR FAy Ate . 4 83'6 7 7 -57; -p/
Address, License #
Signature of Offic r(s of potation
•
Insulation Permit Information
.... , c., .2; r, - /a..f+b._ q//8 taiior. sic. F o 6{o,,, Y /c n /G (9ro� Y86 -BSS S
Insulation"Contractor's Company Name & Address eg3o i Telephone
•
Page 1 of 2 9107
Application #
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technidan 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 Hamett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and if ma 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.
/0.//o
Signature of Owner/Contract Icer(s) of Corporation Dat
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
General Contractor Owner X 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.
X 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. 400 1
Company or Name: �\11 C � 0 p cVIlte /,
Sigw/Title: - kg...4 \ on I ConRA;nJott Date: /a//5//
Page 2 of 2 9/07