DOCUMENTS •Each section below to be filled out by Application# 14-1 2�
whomever performing work. Must be owner
or licensed contractor. Address,company Harnett CountyCentral Permitting
name 8 phone must match information on g
license. PO Box 65 Lillington,NC 27546
Phone 910-893-7525 Fax 910-893-2793 www.harnettorg
f_ Ao Ilcatlon t.r Residential Bulldina and Trades Permit /
Owner's Name: der2 f L the Aw,+hlJ Date: /Z/r//7
Site Address: /O r/ Nu.�/�S Lr. an-gen "0-454 Phone: 9/0- Z gr"' r//7/
Directions to job site from Lillington:
Subdivision: Lot:
Description of Proposed Work: #Bedrooms: 3
Heated SF 223? Unheated SF /0203 Finished Rec Room? Crawl Space/lab ( )
TCCdu/1d/e.6µ'/f«C
General Contractor n
/9- 77Y-6314
Building Contractor's Company Nyme . Te(e
33OoTf{trs+-Dov„ 07372 1/3 ,.651 3465
Addre v License#
Must sign&till out second page
Signature of Owner/Comractor/Officer(s)of Corporation
Electrical Permit information
Description of Work Service Size: Amps TPole: yes/no
//lain 514'tch ?/o-f',f Yfl3
Electrical Contr ctor's Com pany N me Telephone
36b F /114/A f>/, 6e.a,4p ,t/C .1 vis 2 3,2-76
Address License#
Signatureof Officer s) of Corporation
Mechanical Permit Information
Description of Work.
,4s-e ?e.ofi C4T.2c 9/d' 947- 77o7
Mec��ica Contract s CompanyN eQ ,/L g ?27 Telephone 023
3Sy/
JSP u /S/So/ Cvr /v
Atltlress } #6 License#
Signature of dtficer' (s)of Corporation
Plumbina Permit Information
Desa'�ippti�qfn� ork qq Baths
NY's rtJp { p 5Jir— 770-/0/6g
1o'?/Plumbf/ e4-10,na rtafl Company
' A&.t ,✓( ;7330 Telephone /o /1,2V
Address '✓ License#
Signature 6beffiber(sl of Corfsfithion
Insulation Permit Information
Insulation Contractor's Company Name&Address Telephone
Page 1 of 2 9/07
•
Application#
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 as known to me 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 r nsibility to notify the Haman County Central Permitting Department of
any and all changes.
/21.5-4 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 _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. - ® �C
irdeC Qt</ 7
Company or Name: ---TCC 4 / ,1 r
Sign w/Title: t0 PC'60r/N f eal Date: / 1/`7//7
Page 2 of 2 9/07
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 11/30/2017
Entry #: ]63]45 Initially filed by: Burtonbr
Designated Lien Agent Project Property
Print & Post
F idebry National Title Company,LLC PIN-9535-033465000 PIE) 09953500201 0 f10
104 Paulus Ln
ox... ..knmomm .. Cameron,NC 28326
♦ears...19 ii4WWIST Sore 5mt Raleigh,SC Harrell County � +�
Int Contractors:
Fiume:HS-700-73M Please post this notice on the lob Site.
Far 915-45c-s211 Property Type
Suppliers and Subcontractors:
emus smmn..kmae tote,_ Scan this image with your small phone to
ew.this filing You can then file a Notice
1-2 Family Dwellin8 toLien Agent for this proles.
Owner Information
Date of First Furnishing
Jerry Sr Lori Paulus
104 Paulus Ln
I2i0112017
Cameron, NC 28326
Usa
Email nonefas one
corn
Phone:910-845-0171
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