BUILDING 09109(11 Application#
Harnett County Central Permitting 14 nen
PO Boz OS leempinn NC 27548
Each sedan below to be Med out 9100037628 Fax 910 893 2793 view hamett au/pewee
by whomever performing work
Must be owner or Sensed
cenaaamr Address company Application for Residential Budding and Trades Permit
name&phone must match /�^ 1�' -/
Owners Name (JJrfai bf noml �� Date lu51l7
Site Address 3U0 Anna sl- Phone Phone 414.Q41S.Q1
Directions to lob site from Li lington 044 h✓•On ',Crow.SI- .nit to yet S t S'f SI-.
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Subdmsion MenAAu1S �Maw c &We— Lot OA
Desorption of Proposed Work 1 0 of Bedrooms 4q
Heated SF MIR Unheated SF SI, Finished Bonus Room, N Crawl Space Slab X
General Contractor Information
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Building Contractors Company Name Telephone
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dress c-n- v Email Address
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License
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Desonphon of Work . .a 4. Service Size is Amps T-Pole‘Vies No
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Electrical Contractors Company Name Telephone
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Address `'^`�''� Email AtIdNilis
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License#
f hanicaUNYAC Contractor Information
Description of Work NWIAft Air 33L 7G4•G730
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Mechanical Contractor s Company Name Telephone
100 St >S 9-1 e.krlw406 AM 77nv_ toar3Jsdrn211llaoVlnL1
Address EmiaaAAddress
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Plumbing Contractor Information
Desooption of Work VORA&n9 —Cv4,i( #Baths
elirkricirlftt PWwtlnilA 4 QtQ `R6 .4193
Plumbing Contractors Compen Telephone Phone
_v.3)1.10 A tit vt5ovEn. O.la,ea") ?"1576
Address EntalTiddreMhwaa"mal"
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CaPt
72.1 S2.--
License#
` Insulation Contractor Information
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Ineu tion Contractors Company Name&Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
Homeowners Applying to Build Their Own Home
Please answer the fallowing questions then see a Paint Tsdinl an to determine ti you quay for panne 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 Harnett County Zoning Ordinance. I state the information on the above
contractors is correct as known to me and that J affirm that I have obtained all listed contractors
permission to obtain these oermbtg and if gay 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 noes.
EX MIT FEES-8 Months to 2 years permit re-Issue fee Is$150.00. After 2 years re-Issue fee
is as per current fee schedule.
Tom, 10/5/2017
Signature of Owner/Contractor/Marne)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.
Company or Name:wJH,LLc
T
Sign wyritle: Date:10/52017
PESIDEDM DAL BUILDING APPLICATION 1"12 04/11
DO NOT REMOVEI
Details: Appointment of Lien Agent plied on: 09/76/2617
Entry #: 722246 Initially Wed by; wjA2013
.Designated Lien Agent Project Property I
II I Print & Post
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i Owner Information
L W)N,L4C .
3900BsttlePwod Ave UM 230
Cbeetmo,NC 21410
•Wibd Sister .
Hese:OaBIbQweddvmeyhames.tm
Pham.919-0954654
New Commis(0)
Teeleleel Support Netlbr.OBB)690.7314