BUILDING 09/09111 Application#
Harnett County Central Permitting
PO Box 65 Lillington NC 21546
Each section below to be filled out 910 893 7525 Fax 910 893 2793 www harnett org/permits
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name 6 phone must match O
Owners Name fn;chole\ e uotau er �r Date l-(o—lfl
Site Address Phone
Directions to job site from Lillington Ta Ke QV) to-wants Rn,;er Audra rtv1- nn-hb
Oka Cows R&Sk4i Skcca ta- un4r.\ you_ 5e-1— kn aa,K;n Rd. T4(14
r; )4it on+o 'CrRo . +4,tv. r; 1l11- onto Grejor7 Circle_ Tab ;s 1. 5 m;les on lef'f.
Subdivision Lot Z
Description of Proposed Work NPuA 410.4 5 r #of Bedrooms
Heated SF 14SS Unheated SF Finished Bonus Room'? Crawl Space ✓ Slab _
General Contractor Information
50.4.3 *Bas+en. Cons+tUC Oto eF a.'•es CreeK 9l9-asa-a443
Building Contractors Company Name Telephone
Po aof \St1 3t.:es CreeK NC. Q756(.0 n chat I@ 5:—Nc•corn
Address Email Address
CoalP49
License#
ee c I Cor ori t o
Description of Work t4G.A-+ etaService Size Ob Amps T-Pole _Yes_No
Pbk',cK Etec\-e,ca\ Cbn+racter s `Ito- set-5- S-7,
Electrical Contractor s Company Name Telephone
130 4 Inw,k3 St L.l\,.aJtoN
Address Email Address
Het Kw
License#
Mechanical/HVAC Contractor Information
Description of Work 1'4e4-1NU 4C
Tim Nee-V,b40q * A;C X19 -a9I -033(0
Mechanical Contractors Gerllpany Name Telephone
gag lur\:nJ\cnl Qr\ (rakes Q 34
Address Email Address
PI U014
License#
Plumbing Contractor Information �1
Description of Work t- t. ) P1�1m b; +.I3 #Baths a
I, R G1ouer P\.rmb.t.)Qk 1n 919- Sao- otacp
Plumbing Contractors Company Name Telephone
Po Box 'Rio 4 Bens ON taCa75o' 1
Address Email Address
6795 $
License#
Insulation Contractor Information
Fr, C:i
Insulation Contractor s 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 signing below I have obtained all subcontractors
permission to obtain these permits and if ay 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 as per c rrent fee dule
� ( 9 62— /1
Sig lure f Owner/Contractor/ (s)of Corp anon 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 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 n
Company or Name 550.l6e015'}ett.l tolls*uc-}4 c5c Bw:eS Crte K O
Sign wrfitle //.'�'/ __� _ Dale /-(0- (7
DO NOT REMOVE!
Details: Appointment of Lien Agent Flied on. 0912012017
Entry If 730145 initially filed by:
SouthBasternCOnatruclion
Designated Lien Agent Project Property Print& Post
Chicago Tide Compnr.LLC
954
OMlne.. xu lunm.mn _ 95C4rnWry Cu ❑46Li ,NC 11506 1
Ilurcn Cunt
A001303319 Wlinty A.,Sum Sml0.JerC
no Contractors!
9b..:811.690.73n Property Type Please post this notice on the Job Sae.
n:913-119.5231 supplien.al Subtontrutton:
[nN: u iIliemnxmn. x . ..
Sew ibis inuye with your wl phone to
Ll family Dwellini ww 0asfdilp.Ywcnnten iileallotke
m Lkn Ages for tbir point
Owner Information
Date of First Furnishing
Michael Evm Weaver Jr 09129/2017V 10 Mathews Millpond Rd
An®b5 NC E75131
Dolled Slain
Esti car573@tcloud can
Phone 910-309.4506
V'ew Co,,nenla 10)
Technical Support 0051lne(813U1610-0309
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