BUILDING APP Application # 4' 45-00414q�
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546
Each section below to be filled out 910-893-7525 Fax 910-893-2793 www.harnetl.orglperm its
by whomever performing work.
Must be owner or licensed
contractor. Address,company Application for Residential Building and Trades Permit
name 8,phone must match
Owners Name: jaM 02-(A-1 k` /� //
Date:
-4-i -I
9
Site Address: /0 (QOL& fkLn nJ,l Phone:: Li2)i/'5-1115Directions t94ob site from Lillington: Jwy 240 SUu1�. tIo-ni . • oat,
le,V1- OIL I4 /Wt. 12c
Subdivision: Lot:
Description of Proposed Work: AQ✓Gy #of Bedrooms: 0
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: Slab:
antral Co ractor Information
j1ci\It Maxsohwl \ 4a'v 0ic)5ist- -ivy*
Building Contractor's Compaahby Name Telephone
Address Email Address
Lice se#
Electrical Contractor Information
Description of Work Service Size: Amps T-Pole:_Yes_No
(awm.ev)
Electrical Contractor's Company Name Telephone
Atiress Email Address
License#`
Mechanical/HVAC Contractor Information
D- cription of Work t4
a ire/04
echanical Contractor's •ompany Name •h°
•ddress Email Address
LirPlumbing Contractor Information
Descr • on of Work aifP # Baths
641
Plumbing Contractor's Company Name Telephone
,MC.
Address Email Address
License#
Insulation Contractor Information
�/fr
Insulation Contractor's Company Name 8 Address Telephone
*NOTE: General Contractor I owner 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 sinning below I have obtained all subcontractors
permission to obtain these permits and if ai 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 per current fee schedule.
//� : ^� �
.- e of O - / !r J Xd/ i di
:ign,e 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 u.""</her 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 permtt 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 N q y p
?i n w/Title: I cC s tats./✓l2 Date: 1 )cavi /�-7