BUILDING 09/00111 Application#
Harnett County Central Permitting L- d^ 3(s 4
PO Box 65 Lliirybn N0 27548
Each aedon below to be Med out 910 693 7548 Fes 810 893 2793 www horned arg/pennrh
by whomever performing work
Must be owner or licensed
conbmter Address company Aoobcabon for Resrdenbal Buddina and Trades Permit '
name a phone must match Vied) 11
Owners Name rcnt. PCM,1� Date
Site Address 31111 Phone 41.101,24,R1
Directions to job site from Lillington 111.4 a/. on f.CrOcsd•SI• ..j-ar.'ant S i S4 SL.
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Subdivision M iM/1nfi1S Ai- 13ui'/c Cr//1"- Lot
Description of Proposed Work -5F - #of Bedrooms
Heated SF int Unheated SF 5Z.- Finished Bonus Room2 Crawl Space _Slab x
General Contractor Information
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Budding Contractor s Company Name Telephone
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Detonation of Work .. r 11tCl_ra Service Sias s! imps T-Pole✓1'es_No
UJ-3 .7541
Electrical Contractor s Company Name Telephone
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Address Email Atldfais
1t4,21
License#
Mpf hamcallHVAC Contractor Information
Description of Work Nl.614AQ , ATV"At
0.awl,Ccra-Atic 111 33G•74k.417315
Mechanical Contractors Company Name Telephone
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Address EmaaAAddress
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License#
�i•5 Plumbma Contractor Information
Description of Work Writ(w 'i' 4((A ^ #Baths �2
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Plumbing Contractors Company Name Telephone
,31.14 A. 0tvS 'nen. 0.1a (d0n ?"15-eDTw+rdnr451211 nlmvl/lydyrApd,WU:
Address Email Addres Cart
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License#
Insulation Contractor Infomiattop r r
xtLEAERS hSUIcL41ova 4va•'188 ' soy
Insu ahon 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 following questions then see a Permit TechnIclan to delmrnlne It you wally for permit urtw Comer 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? j 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 I 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 N correct as known to me and that J affirm that I have obtained all listed contractors
permission to obtain these',snub and It opy 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 tatiOlanges.
EX MIT FEES-B Months to 2 years permit re-issue fee is$150.00. After 2 years re Issue fee
is as per current fee schedule.
au" 10/5/2017
Signature of Owneer/Contractor/Oficer(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 corporations)performing the work
sot 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 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
Sign w/Tide: nts'e 6l Date:10/52017
PESID[NrIAL BUILDING APPLICATIGN 2 rl 2 04,1
DO NOT REMOVEI
Details: Appointment of Lien Agent
Entry ♦: 717317 Flied on: 011/16/2017
Initially flied by: wJb2013
'Designated Lien Agent Project Properly
Print & Poet
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5300 Battleground Ave Sults 250
tleommq NC 21410
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Phan:919995.5654
Vim Command(0)
Tevkalid Support Nadine:(9881690.7544