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TRADE ELEC • Each section below must be filled out by Application # ,* O .57g9 c— c/f whoever is performing the work. Must be Harnett County Central Permitting owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546 company name 8 phone must match 910- 893 -7525 Fax 910- 893 -2793 www.harnett.org /permits information an state license. COMMERCIAL Application for Building_dnd Trades Permit Owner's Name: / �r?l' — l� `/ .Date: /— / / / / C Site Address: 3 �� � � /F217�r0 Phone 9/ a 3 ( / Directions to job site from Lillington: Subdivision: Lot: Description of Proposed Work: Heated SF Unheated SF General Contractor Information: Building Cost $ Building Contractor's Company Name Telephone Address Email Address Signature of Owner /Contractor /Officer(s) of Corporation Licens Electrical Contractor Information: Electrical Cost $ 3 4ft 5 07) Description of Work Service Size: ( Amps #T -Poles Lac244 /5 ��d G, �2_i! ecl ,E -G l> i Name Electrical Contractor's Company N Telephony , � �,rc,�' L ���� /,5er-015",C ) .4-4 /1 i rk A dr ss Email Address Signature of Owner /Contractor /Officer(s) of Corporation License # Mechanical Contractor Information: Mechanical Cost $ Description of Work # Units Mechanical Contractor's Company Name Telephone Address Email Address Signature of Owner /Contractor /Officer(s) of Corporation License # Plumbing Contractor Information: Plumbing Cost $ Description of Work # Baths Plumbing Contractor's Company Name Telephone Address Email Address Signature of Owner /Contractor /Officer(s) of Corporation License # Insulation Contractor Information Insulation Contractor's Company Name & Address Telephone *NOTE: General Contractor must fill out and sign the second page of this application Sprinkler Contractor Information Sprinkler Contractors Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Fire Alarm Contractor Information Fire Alarm Contractor's Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Driveway Access - NC Department of Transportation Driveway Access /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 Harnett 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 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 charged at full price per current fee schedule. 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 th em. Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance c overing 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. 0-2/915 , Company or Name: `, 1 `� N 4 G�? /� / Sign wffitle: '. Date: �J /