BUILDING MOBN 1 Application#?
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Eachsman bebhe filled out PO Boxall Edlington NO 27648
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contactor Address company /tgglrcetion for Residential Building and Trades Perms
name&phone must mall* ��J/
Owners Name ti, .IUY11 Ik)btt 5 Date
Site Address 3'1 t! kiwis!' Phone QIQ•4QSSia$c/
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Subdivision Manot&LIS A.Fnu IC U-ie _ Lot Atria
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Description of Proposed Work 5 1'2 #of Bedrooms 3v
Heated SF W1a Unheated SF 22•••• Finished Bonus Room't Crawl Space _Slab }`
General Contractor Information
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Building Contractors Company Name Telephone
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Description of Work .e ifit Service Size AO Amps T-Pole✓ Ves_No
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Electrical Contractor s Company Name Telephone
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Address Email Midas
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License#
Mp[chanlcal1HVAC Contractor information
Description of Work NL6llnq 4 Air
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Mechanical Contractors Company Name Telephone
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Address Emai Address
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Plumbing Contractor Information
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Plumbing Contractors Compan$Name Telephone
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License#
` insulation Contractor Information
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Ineu*hon Contractors Company Name Si 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 weskits then aae a Permit Technician to determine It you qualify for permit under Owners Exemption.
Questionnaire per G.S.67.14 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? 1 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 d 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 l affirm that I have obtained all listed contractors
permission to obtain these permits and If pp1t 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 Hamett County Central Permitting Department of
any gag ejsgonges.
EX MIT 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.
T,4aaa 10/5/2017
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 corporatlon(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 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 wRitle:
T Fi6.1 Date:10/5/2017
RESIDENTIAL BUILDING APPUICdl IONI 2 of 2 0411
DO NOT REMOVE:
Details: Appointment of Lien Agent
Ming M: 722750 Filed on: 09/15/2017
Initially flied by: wfh2017
D*signaled Lien Agent Prof eel Property
Print & Poet
loranntta Joanne Company I MBT106
376 Ana SI 111_
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Owner Information bLim Apia lx Us pitied.
WJB,LLC
3300 BMleQ9oad An Bulb 299
Onwbat% NC 11410
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Agan 919991-16191-504
View Cnmmnb(0)
tb slnl SOBpn BotWn:(188)690-Thu
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