BUILDING UUIUUII 1 Application s
Harnett County Central Permitting /7- S7I0 'f/ ,07
Each section below to be Oiled out PO Box 65 Lillington NC 27548
910 893 7626 Fax 910 893 2793 www harnetl mg/permits
by whomever performing work
Must be owner of licensed
=Onto!' Address company Application for Residential Building and Trades Permit
name 8 phone must match O -7
Owners Name th„,„ c....liStrat:' f -
tNC, Date 6 /
Site Address 3 9' uery ISIS hr Phone nGo3-MS-
Directions to lob site from Lillington fov. Ned rlt kt a-bO ow, 3a.;lC ef{ oaj 'a//ii
for ISaulri,, Le:4 Do shalt bah. 2.d kin YRatrle , Auer, Rad n a /d#.
Subdivision %err Pord /1 Lot (O0
Description of Proposed Work Neu) CONS71tut?('s/ - ,Sice #of Bedrooms /
Heated SF ISE Unheated SF 793- Finished Bonus Room'' Crawl Space _Slab Y
General Contractor Information
Buq IAA Laric-Iru.Gt:er1 I pin. 919 603 - 776 C
IdiAg Contractor a Company Maine Telephone
2s3-o Ca N-Iol I). Ste /aSGeerc40rit 27122 eduerI@/.14/44 uFes.Cat
Address Email Address /
ifbz?s
License#
mi�tral Contractor Information
Description of Work Ale“) eoars1ruti iOAl Service Size ,ZOO Amps T-Pole _Yes_No
t. A. Tacksod 679-4.-fritt_ 9/9' 730- /Ls/
Electrical Contractors Company Name Telephone
9261 2ale:gktd. &atsoa,NC 27.5-o'f
Address Email Address
i � yN
License#
echanicall�IVAC Contractor Information
Description of Work /veuJ Coin frod 'A/
(1ert:0:e4- Neat oat A:r 9/0 858-06°°
Mechanical Contractor a Company Name Telephone
9?l6easetAaktAI. Jgaber3Jre-t '18357
Address Email Address
02o0212 /13 66561
License#
p�lumbbnn Contractor Information
Description of Work eul (10/17,V.7%/1 #Baths .2. .-
14nZ s /uk,in9 919 31-0- 9933
Plumbing Contractor s Company,� Na a Telephone
3/60-A OisrPd. /'/e/ /ear Alt 2712']
Address Email Address
ZZ/S2-
License#
Insulation Contractor Information
Tatram ..ThSa/atoe/ /? /t1-D999
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 pv sinning below I have obtained all subcontractors
permission to obtain these permits and if apy 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
EXPIRE PERMIT FEES-B Mon s to 2 years perms a-issue fee is $150 00 After 2 years re-issue fee
is asp curreedule /��� 7
eDaleturio Owner/Contractor/Officer(s)of Corporation
_ I
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
General Contractor _Owner /77---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
!/tHae 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
17 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 /q�
Company or Nam, Aim Ow;4- O41,_LAIC4 p
41 ', mei $ -/7
Sign w/Trtlej Date