BUILDING 00100111
Application# /
Harnett County Central Permitting L 0^aD 7
Earh B1101011 below to be Sled outPo Box 68 Winston NC 27848
by whomever perronnr g work 910 Bab 7526 Fax 970 e09 2768 www hornet!orgywmde
Must be owner or keened
contractor Agresseinrnkpoohaatron for Residential Budding and Trades Permijphone musr ma
Owners Name (/J/](,(.tIL)fj 414$ Dale lni Si 1'7
Site Address 342.Anna-S+ Phone 4IQ•QQSS4Sq '
Directions to lob site from Edlington 141g4 a/. ail P.Crawk.SF ..411 tails 1st 57.-.
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subdivision M tnnlnulS Al Buis s CYUe. Lot
Description of Proposed Work are- #of Bedrooms 'tk
Heated SF It-1'16- Unheated SF Si Finished Bonus Room', Crawl Space _Slab x
� � � general Contractor Infonnatrop��22''�
Building 11—L ors Company Name Telephone3&arZ-f,l/a,
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Description of Work a 1:Cirn r rservice Size r• Amps T-Pole✓ yea_No
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Electnoel//�IContractor__s Company Name Telephone` �y'
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ManlcauHVAC Contractor Information
Description of Work 1-161.14A1 Airh
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Mechanical Contractor a Company Name Telephone
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Address Erna Address
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License#
plumbing Contractor Informattog
Deskption of Work Pit lMloti9 inectfria #Baths
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Plumbing Contractors Compant Name Telephone
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Address
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Insulation Contractor Informatrog
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Insu bon 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 question then sea a Permit Technician to determine If you quality for permit under Orman Exemption.
Questionnaire per O.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 br 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? ✓ Yee 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 1 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 Hemet County Zoning Ordinance. I state the information on the above
contractors is correct as known to ma and that)affirm that I have obtained all listed contractors
permission to obtain then oermjp and If pay changes occur Including listed contractors,site plan,
number of bedrooms,building and trade plans, Environmental Health permit changes ar proposed use
changes, I certify Its Is my responsibility to notify the Hamett County Central Permitting Department of
anyEXPIRED-PERMIT 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.
Tau. 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 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 mare 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
Sign w/Title: read* Date:10/5/2017
PBSIDrNTIAL BIIILCING APPLICATION 2 tri 2 Bytl
DO NOT REMOVE!
Details: Appointment of Lien Agent
Flied and 0gf15y7017
Entry 0: 737316 Initially filed by: w3h2013
I Deolgnet.d Lien Agent Project Property
Print & Poet
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Owner Information I mUn Apeot Por Ml.pmJmn
Will.IMC
33001.ttI.rad Ave Salm 390
thermboo,NC 21410
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Nom:9194:9544:54
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Teelnanl Yeppon gm W:(918)690.734