BUILDING 09109111 Application#
Harnett County Central Permitting i `�SCO 1 akI
PO Box 65 LMrglon NC 27546
Each emanon below to ba hued out 910 893 7525 Fax 910 893 2793 www hareem orypermits
by whomever psdonnin9 work
Must be owner or licensed
contractor Adorns company Application for Residential Butldina and Trades Permit
name 8 phone must match /J 1
Owners Name 6itila r•P I+enc- 2ikesS Date��2��1`1
Site Address VV s100(0 C!4 Us 92.1 phone (110-K-4-9235.
Directions to lob site from Ldlinglon
Subdivision -1-Olit+o1ks✓. t-64)1 I9r Lot
Description of Proposed Work MPLO Opviis-bn4d4fek #of Bedrooms if-
Heated SF 2S6 7 Unheated SF 370V Finished Bonus Room/ (es Crawl Space _Slab fel-S-74.t r
General Contractor Information
S i pv at r c Lrk &t. 1)u-asters 9117 4 4k�Q
Building Cohtractors Company Name Telephone
lao4 N . 141.4“.... sr . ?7NL'
Address Email Address
Li9y3
License N
Electrical Contractor Information
Description of Work f t Oc�'ri c A I Service Size WO Amps T-Pole _Yes_No
6t..Fvrti Circ{... 910 — '23 -193'7
Electrical Contractor s Company Name Telephone
Ills Par,., or . 4e- tA1s Nc, ae3` 2'
Address Email Address
PAile2N
License#
Description of Work bs�n gilninUHVF oI *
QB
Mev
F92._ -8827
Mechanical Contractor s Company Name Telephone
IU)1 MesL.t DT, y w,1 Ne 0:09
Address Email Address
11194
License#
plumbma Contractor Information
Description of Work Pi.7nd' #Baths
LIZ. (dint Lt(u.. 4kr
Plumbing Contractors Company Name LJ Telephone
P,OI. Ro#r '74fr77- $e tsI-1 Nc a?so'r'
Address Email Address
'7958
License#
Naulatton Contractor Information
Ion0 ,,i,,.bentani l�74. W-49—?NB
Instils Contractors Company Name 8 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 slate the information on the above
contractors Is correct as known to me and that by mama below I have obtained all subcontractor'
permission to obtain these(permits and if ppy changes occur including fisted 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-S Months to 2 years permit re-issue fee is 5150 00 After 2 years re-issue fee
is as per cu nl fee schedule
Signs of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C O S 87-14
The undersigned applicant being the
_General Contractor _Owner OfhcerlAgent of the Contractor or Owner
Do hereby confirm under penalties of penury 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 pnor
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 Name cherVI/ ��f/�e� /' `r a �7
Sign w/fdger�_ 45 //1i Cc. r/ (N/('f icy-Or Date 9-0i7 -7
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 09/27/2017
Entry M: 7211213 Initially flied by: IarrydaughIry02152
Designated Lien Agent Propct Property Print & Post
bn men The lnnunnce Convoy .11106 Old US A=1
Lill melon NC 27541, .0
thane- an
ndareteIn 14 Bergen SSt.Seth.3N.Rcl.ab.NI( County
a16u1 Con raclure:
Phone.xxxnh.nv4 Prop.rty Type Please mums nourc on the lob sue
en:a6Yrfn1 So PPlien and Subcontractors:
Emnl,aptIII hmmc c.mnthist w116 vont Elaine
1-2 Family Dwelling view'his Bite You 9ben file a Notice
10 Lien Agent ror ens project
Owner Information Date of First Furnishing
9'enurnre unntu u n,lders lormr0n
1200 Main Si
L'llutio,i NC 27546
Untied Stales
runtcu te,rod abri,ynnd elan
Phone e10-1192_929e
glen.Co"nenu tel
Technical Support hotline:00181% 0.111R4