BUILDING 09109111 Application# I
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Description of Proposed Work Sf tZ #of Bedrooms 5
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*NOTE General Contractor must fill out and sign the second page of this application
Homeowners Applying to Build Their Own Home
Please answer the tollowtng questions then see a PermIt Techs an to determine It you quay for permit under Owner 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 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)afflnn that I have obtained ell listed contractors
permission to obtain these marmite end if goy changes occur including Rated 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 iestqtainges.
EX MIT FEES-6 Months to 2 years permit re-issue fee is$150.00. After 2 years re-Issue tee
is as per current fee schedule.
T-4y, 10/5/2017
Signature of Owner/Contractor/OffIcer(s)of Goiporetlan Date
Affidavit for Worker's Compensation N.C,G,S.87-14
The undersigned applicant being the:
General Contractor _Owner I 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
set forth in the permit:
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✓ 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 wlritle: 7-41.46"/ Date:10/512017
P.ESIDENTIAL BUILDING APPLICATION 2pI 2 04' I
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 09/18/2017
Entry d: 724749 • Initially 11led by: 0112013
Designated Lien Agent Project Property
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