BUILDING • Each section below to be filled out Application # 106000
by whomever performing work Hamett County Central Permitting
Must be owner or licensed PO Box 85 Ullinglm, NC 27546
contractor. Address, company 910-893 -7525 Fax 910-893-2793 www. hamettoryfpermita
name & phone must match
Application for ResideMlal BuIIdina and Trades Permit
Owner's Name: Serre+evy A- OM that 1-441MMGMS Date: 12/27/
Site Address: 15 MerAnw View C4 Fixer Vain, NC Phone: 919 - 5b3t
Directions to job site from Lillington: }dust in F .nm5
pal moor. CI :awe_ 1'Z /tCb
Subdivision: Nr,i}ir , C.rnS Lot 14
Description of Proposed Work:Twnin, ?Ana *b gtelta"^ t M4tc -%o QpryS # of Bedrooms: q
Heated SF: 4&O0 Unheated SF: 2S0 Finished Bonus Room? *S Crawl Space: ✓ Slab: _
General Contractor Infonnatbn
T j- lsommnmg
Building Contractor's Company Name Telephone
Ad ss Email Address
Otalver
g natuYe of 0wr1 er/Contractor/Offioer(s) of Corporation License #
Elect al C ntr#ctor Infurmatipq
Description of Work Wir AWAC Mf r Service Size: 200 Amps T -Pole: _ Yes No
0- 11
'Treat y 04
Electrical Contractor's Company Name Telephone
Add ss Email Address
//j ...- OWner
na Owner /Contractor /Officer(s) of Corporation License #
$echanicaltHVAC Contractor Information!
Description of Work A/ow 1. f 4. n fjord Ray 4 DA- writ:
P inven
MechanlL`a1 Contractor's Company Name Telephone
Add s �i/ Email Address
,'„ Ow+ner
S' ture of Owner /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
•
Signature of Owner/Contractor/Officer(s) of Corporation License #
jnsulation Contractor Information
Sr era AarwmonC OUnPr
Insulation Contractor's Company Name & Address Telephone
`NOTE: General Contractor must fill out and sign the second page of this application.
Homeowners Applying to Build Their Own Home
Please answer the folbvMg questions then see a Penne 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 as 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 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
is �`V'f°"
as r current fee .
.N- "'- /ZJ 2
Si ture of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.IS. 87 -14
The undersigned applicant being the: J
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(a) who has their own policy of workers' compensation insurance
covering themselves.
X 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, dm or corporation
canying out the work. ' 1
Company or Name' S e n�� I'�w�
Sign w /Title: stir ,�,(5(r,.+ -a...
0 ..ner Date: )2/VSO