BUILDING APP 09/09111 I Application#
Harnett County Central Permitting f '5n(\ 0.21 0E5
Each section babes to be filled out PO Box 65 Ulbnpton NC 27548
by
Each
whomever$ bo Plow work 910 893 7525 Fax 910 893 2793 www hamett cop/permits
mits
Must be owner or licensed
contractor Address company Application for Rgpidentlpl Budding and Trades Permit
name 3 phone must match
Owners Name/71GMaSIJ. -r Es; IUP-eirSS Date a"c l 17
Site Address tD 1(Q Mali "N fd. ectrwIr'i1\ ,tqC .Fc10 phone(J C)687-H7,'
Directions to job site from Lillington 1 . t t t. . n► . 0 . A. io
NCO- fur n (A 84 n(‘I 1\ e lis `iA lQ J( t itisTA '►son
Subdivision i, Lot
Description of Proposed Work 111!\(Dm QC[,I�$$i 4A. #of Bedrooms 3
Heated SF Unheated SF J Finished Bonus Room', Crawl Space Slab
General Contractgr Information
Building Contractors Company Name Telephone
Address Email Address
License#
Electrical Contractor Information
Description of Work Service Size Amps T-Pole _Yes_No
Owtr\er
Electrical Contractor s Company Name Telephone
Address Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work °or\n,r
Mechanical Contractor s Company Name Telephone
Address Emad Address
License#
Plumbhnn Contractor Information
Description of Work #Baths
Plumbing Contractor s Company Name Telephone
Address Email Address
License#
Insulation Contractor Information
0(0/Zr
Insulation Contractors Company 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 in signing below I have obtained all subcontractors
permission to obtain these permits and if as 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
�s asFIer current fee schedule
�1P)-ICcVAL --e 744:17( —/ 7
Signature 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 4 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 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
Company or Name
Sign w/Titlec,1J � ,jd/il n1L .��- C WAX Date '-'62) J/ 7