BUILDING APP 09/09/11 Application#
Harnett County Central Permitting 1]- 5004 18 ii2
PO Box 65 Lillington NC 27546 -
Each section below to be filled out 910 893 7525 Fax 910 893 2793 www harnett org/permds
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 Rix, } v Q 4 Slot* Date l5-4(/b- Zpi7
If
Site Address -TBI 1-P3 21 WET Li Ii)H1tnTCah/ Phone qlq-770- t3l
Directions to job site from Lillington 1, (A!tJ� 2.7/ GtW T `7 i4-2D.5 ETERA) /�'r BiZ4 J
Z'i 0'1 LEFT 12�'sT m ID�1. _E. - + /1t /
'i
Lott IdFll;i.A KFNINn - ►1435 iiia 2 W
Subdivision M4 Lot
Description of Proposed Work # IA) 5//tJZhLE Prt'►'111 j #of Bedrooms
Heated SF 215 Unheated SF 5419 Finished Bonus Room9 yi5 Crawl Space M Slab
General Contractor Information
5jz b- CUmmiM/4 COnT. (2? ,Az . 9lq-7x>-46/3
Building Contractor s Company Name Telephone
FD gox 1'3 5 5 t9tJ b Hz_
Address Email Address
License#
Electrical Contractor Information
Description of Work i1i lt) EZFCTi27 . Service Size 2a) Amps T-Pole /Yes No
YioitJ ? EL Z fl ' TN- 4W9- 776'7 -
Electrical Contractor s Company Name Telephone
80 RR_ `rk-omns l213 1-1111W10)1)
Address Email Address
2.164
License#
Mechanical/HVAC Contractor Information
Description of Work 2 -/iv4}[. . y5Tc-b1s
i2ou,v►9 4,k p0- 949- 7707
Mechanical Contractor s Company Name Telephone
370D 05 15 •coi C)1n.Tt-
Address Email Address
23549
License#
Plumbing Contractor Information
Description of Work A/E/A) Kornis;tilt, #Baths 3
cv i rz pc irVinvo 9►n- 810- 22gq
Plumbing Contractor s Company Name Telephone
553 71 Qzt1 i-i D►2 _ki Il/t l 7t,/L)
Address Email Address
31576
License#
Insulation Contractor Information
Irzi Cr-ro ft ut, itor) '10- if No- 885-5--
Insulation Contract s Compan Name&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 to me and that by signing below I have obtained all subcontractors
permission to obtain these permits and if ate(changes occur including listed contractors site plan
number of bedroo building and trade plans Environmental Health permit changes or proposed use
changes I certif it I- my responsibility to notify the Harnett County Central Permitting Department of
any and - ch- ges
EXPIR-' • -MIT F ES -6 Months to 2 years permit re-issue fee is $150 00 After 2 years re-issue fee
i - : • ent fee •chedule
17� IC • ' uzi- ?_,O
=„ il • •wner/Contractor/Officer(s)of Corporation Date r, ?
Affidavit for Worker's Compensation N C G S 87-14
The un er .ned -,•plicant 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 i i�.4kI „ ,•r.
Sign w/Titi _ Date /5--W-,- Zor 7
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