CHANGE OF CONTR 09/09/11 Application#
Harnett County Central Permitting /7`5 CO c / / 70
PO Box 85 Lillington NC 27546
Each section below to be lied out 910 893 7525 Fax 910 893 2793 www Arnett orypemna
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Budding and Trades Permit
name 8 phone must match
Owners Name Date
Site Address Phone
Directions to lob site from Lillington
Subdivision Lot
Description of Proposed Work #of Bedrooms
Heated SF_Unheated SF Finished Bonus Room' Crawl Space _Slab
General Contractor Information
Building Contractor a Company Name Telephone \
Address Email Address
I
License#
fleetrtul Contractor Information
Description of Work Service Size _Amps T-Pole _Yes o %
1
Electrical Contractors Company Name Telephone , VI' (/�(\
Address Email Addres-- ' t `
License#
ylechanlW/HVAC Contractor Information
Description of Work 1„S; sr , / w L. C -q , r 1
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9lq- 7,1 - 5/9 C
Mechanical Contractor aa Company Name Telephone
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Address Email Address
License#
plumbing Contractor Information
Description of Work #Baths
Plumbing Contractor a Company Name Telephone
Address Email Address
License#
Insulation Contractor Information
Insulation Contractors Company Name 8 Address Telephone
'NOTE General Contractor must fill out and sign the second page of this application
I hereby candy that I have the authonty 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 swamp below I have obtained all subcontractors
permission to obtain these permite and if agy 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 current fee schedule
oreSi of ontreclor/ORicer(s)of Corporation Dale
Affidavit for Worker's Compensation N C G 3 87-14
The undersigned applicant being the
General Contractor _Owner Officer/Agent 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 dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name
Sign w/fitte Date