BUILDING 0W09111 Application#
Harnett County Central Permitting 4 22)(4-D-,
PO Box 54'Angbn NC 27548
Each melon below to be hied out 9108997825 Fax 9105922797 www hemott mdpermde
Muwhomever P011Ortnin9WOrk
st be owner or licensed
ccnfrmdor Address company Aoplication for Residential Belding end Trades Permit
nrme 8 phone must match ��,,1t�� h � � •" ��''
Owners Name �yat��.UrV$tJ4 J4oetutS •
Date
Site Address 4112 ANno-S-1-• Phone Q1Q•4QSS.5C1
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Subdivision Mlntitlan I- Rut/S Qrut_ Lot QLP
Description of Proposed Work SFR?, #of Bedrooms J
Heated SF (nu Unheated SF Finished Bonus Room9_Crawl Space _Slab y„
general Contractor Information
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Building Contractor s Company Name Telephone
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Adress J e-.ta1V Email Address
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License#
Description of Work _■ r 1110_r Service Size e• •mps T-Pole Yes_•_No
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Electrical Contractors Company Name Telephone
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[er Email Abatis
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Address
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License#
1d chaneelIHVAC Contractor Information
Description of Work WWIIAt G A r•
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Mechanical Contractors Company Name Telephone
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Address p Emai Address
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License#
�rn plumbing Contractor Information
Des pbon of Work Pt Llh1fottoti CI'f ll'( ft Baths
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Plumbing Contractor a Companf Name Telephone
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Address cart
License#
` Insulation Contractor Information
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Insu Edon Contractors Company Name 8 Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
Homeowners Applying to Build Their Own HomePlease answer Ownersn*under
n.
Quest onnaireaper O.SQ87.14 Regu then ations as t a Permit Issbuei of Building Pn to(Stamina If ermu its Memtor o available upon request)
)
1. Do you own the land on which this building will be constructed? 1 Yes No
2. Have you hired Or intend to hire an individual to superintend and Yes _.No
manage construction of the project? —
3. Do you intend to directly control &supervise construction activities? 1 Yes _No
4. Do you Intend to schedule, contract,or directly pay for all phases of Yes —No
construction work to be done?
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 Yes No
secured the permit? — —
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 normal and if any changes occur including listed contractors,she 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 ea.
EX MIT FEES-6 Months to 2 years permit re-Issue lee is$150.00. After 2 years re-Issue fee
is as per current fee schedule.
T,pays 10/512017
Signature of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N.C.G.S.87-14
The undersigned applicant being the:
_General Contractor _Owner If Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s),firm(s)or corporation(s)performing the work
set forth In the permit:
Has three(3)or more employees and has obtained workers'compensation Insurance to cover them.
Has one(1)or more subcontractors(s)and has obtained workers'compensation insurance to cover
thorn.
Has one(1)or more subcontractors(s)who has their own policy of workers'compensation Insurance
covering themselves.
_Has no more than two(2)employees and no subcontractors.
While working on the project for which this permit is sought it is understood that the Central Permitting
Department issuing the permit may require certificates of coverage of worker's compensation
o person,fi orator insuncprior
to issuance of the permit and at any time during the permitted work from any pcorporation
carrying out the work.
Company or Name:
WJH.LLC
Sign wattle: Te"'AWN/ Date:10/5/2017
PE$IDENITIAL BUILDING APPLICATION 2 of 2 04,II
•
DO NOT REMOVE
Details: Appointment of Lien Agent mod on: 09/76/2017 .
Bnlrp 0: 722219 Initially flied by: w h2O12
J
DeUdnatad Lien Ago n1 !Project Property
Print & Post
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Owner information b 1.I=Alsace NIA*
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Poae:919-99S-5614
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