DOCUMENTS 09/08/11 Application#
Harnett County Central Permitting -56041180 4'1Sa 1
PO Box 85 Ldlinplon NC 27548
Each section below to be filled out 810 893 7525 Fax 910 893 2793 www hemett orprpermns
by whomever performug work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match
Owners Name 3771) Satrracinnt.A....L-LL' Date
Site Address W.anceSe2r e st.r .Ry7.G:.,1.h2?c.a /SIL Phone 9/d- C/-SSOS
Directions to job site from Ldhngton a In N is -Pv-gti b'' SOO�e�•
per
e_iante , C.L.S. %a.-...
Subdivision 'Zhrtie+.if xxnnw./ Lot IP
Descnphon of Proposed Work 5.r....614..1s niAtj'1%b - N #of Bedrooms '+
Heated SF 1Ot.b Unheated SF 4411 Finished Bonus Room" 11ro Crawl Space _Slab X.
General Contractor Informerod
Gars% Ro6,nsern tie meg. LLC 910-401-5505
Building Contractors Company Name Telephone
t.2OD1R.A msec.l Str r ett 6L to k'1 katillsA `/ I Et i y,,�.a1thyir� .. J
orees l . .eS+-
Address mad Address
LJISSO
License#
€lectncal Contractor Information
Description of Wod.'Cl4,V���. kS'l
-nr4eAelr'aB+- Service Size ' .no Amps T-Pole &Yes_No
4Qova 'tcekr IC., LLL 910- r173a.-1937
Electrical Contractors Company Name Telephone
9453 PAAI Drlvcy Ito pe Mills,n7c.. 1s,.trA dl,eAeeJFrlca lb@tJoAeo.t*n
Address Email Address
"i I tf 21-1 - u.
License#
MechanicallHVAC Contractor Information
D7�e�scription of Work Woo) Cos151vuc ',e---
010-1La0, ZNC. ti/0- 4$6-031$
Mechanical Contractors Companyr- Name Telephone
Pt u 34903, fnai4ftcl3-,llLxv._,1.9',ac, ea...40 eexbA.9tnoll.enw
Address Emad Address
GPI 5`1 PH 1-3
License#
Plumbing Contractor Information
Description of W `gay- Q.-zt &ae47.e.1 #Baths
J1.41 )•wire i'll�m.ln , LLC 9lo-'Las- 9939
Plumbing Contractors CompanYName Telephone
P�Scj 1460W2 'Fuyafh_llIpiAJC a83DL elxJIAt•....plast.
Address 1 Email Address
3 2.nip
License#
Insulation Contractor Information
910-Oct- `1N�
Insulation Contractors Company Name&Address Telephone
'NOTE General Contractor must fill out and sign the second page of this application
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 Hamett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that pv srunma below I have obtained all subcontractors
permission to obtain these!termite and if gay changes occur including listed contractors site plan
number of bedrooms building and trade plans Environmental Health permit changes or proposed use
changes I ;;;, rfy it is my - ••nsrbility to notify the Harnett County Central Permitting Department of
any and allang
EXPIRED 'ERM• FE 4- Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
Is as •- n: e�
sltAts
'Kt = = of Owner/Contractor/Offieer(s)of Corporation Date
Affidavit for Workers Compensation N C G S 87-14
The undersigned applicant being the
_ X General Contractor _Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of penury 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 more than two(2)employees and no subcontractors
While working on the project for which this peanut is sought at 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 Na Gar At issinson Non.es3LLC-
Sign wlrmle A ' pan' $✓t— Date •51 1.41$
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