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BUIDING ' Each section below to be filled out Application # by whomever performing work. Hamett County Central Permitting Must be owner or licensed PO Box 65 Lillington, NC 27546 contractor. Address, company 910- 893 -7525 Fax 910 - 893 -2793 www.hamett.org/permits name 8 phone must match Application for Residential Building and Trades Permit Owner's Name: V'fl C-e t. n i cx, em p 115 Date: l c-' 13 I I O Site Address: ,-)i '5 14 P0_41r 0 W 1Drl - Qri 11 , 9 N� Ph ho on : I f7 -4�1p -g�Do Directions to job site from Lillington: 1 Y t ,- L O 5- l r t A - n n 12 r ko 1 : - (-4 c In (tvo Ue_ Subdivision: Pry r 1 f 0 A- Ange nn(_YPP C , Description of Proposed Work: tFrr'ecs rta -Ri J; 1 rli n.. '# of Bedrooms: Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: _ Slab: /� �] Q General Contractor Information /} r -3 ipS Building Contractor's Company Nagle r) Telephone K2 Pu �r�.✓tr k alask,nL rflio©3 66L1P re- tral;naua Addre�s / / //J Email Address Jeu ,...r f (� N I A 4 30, D of ° Signature of Owner /Contractor / Officer(s) of Corporation License # Electrical Contractor Information D: scription of Work Service Size: Amps T -Pole: Yes No Elect' al Contractor's Company Name Telephone Address Email Addr Signature of Own- Contractor /Officer(s) of Corporation Lie # Mechanical /HVAC Contractor Information Description of Work / Mechanical Contractor's Comp y Name / Telephone Address / Email Address i 7 Signature of Owner/Contractor/Officer(s), orporatien License # P mbi Contractor Information Description of Work # Baths / Plumbing Contractor's Corl7peny Name Telephone Address Email Address . / Signature of of Corporation License # Insulation Contractor Informed • Insula ' n Contractor's Company Name & Address Telephone \ `NOTE: General Contractor must fill out and sign the second page of this application. Residential Building Application 1 of 2 03t 10 Homeowners Applying to Build Their Own Home Please answer the following questions then see a Permit Technician 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 th&known to me and if any 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 Hamett 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 perr current fee schedule. h /!3/1 n 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 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. I Company or Name: �yro\ no, , IQr1 r .--Rct r n< L, LC, Sign wTtle: hod- — 1? a n4 fQ r Date: 1 f i3/I f7 Residential Building Application 2 of 2 03 /1D