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BUILDING Application # /D . -75-40- 2-q 733 Each section below lo he filled out Harnett County Central Permitting by whomever performing work. pp Box 65 Lillington. NC 27546 contractor. or. Adtlress. company m co Must owner or s 910. 893.7525 Fax 010 -893 -2793 www.haetl.orglpermits name 8 phone must match e3rrsto L Application for Residential Building and Trades Permit Owner's Name: Wynn Construction, Inc. Date: // # Site Address: /2 /7/ler/ ,'T Phone: 9/g 463 - 7965 Directions to job site from Lillington: 27 W to Buffaloe Lakes Rd. Left on buffaloe Lakes Rd. Left on Cameron Pines Dr. Subdivision: Cameron Pine Lot: 17 Description of Proposed Work: New Construction # of Bedrooms: 3 Heated SF:21? I Unheated SF:S27i V Finished Bonus Room? 7 Crawl Space: i Slab: _ General Contractor Information Wynn Construction, Inc. 919 603 - 7965 Building Contractors Company Name Telephone 2550 Ca tot Dr. Creedmoor, NC 27522 ®�,�7/' mail edward ©wynnconstruct.com Addre % / /� %tfi y� E Address 4 Email // f Signature of b ^ner/ ontr :ctor /ifficer(s) of Corporation License # ( / Electrical Contractor Information I description of Work New Construction Service Size: 200 Amps T -Pole: ✓ Yes No l R. A. Jackson 919 730 - 1251 Electrical Contractor's Company Name Telephone 9261 Raleigh Road Benson NC 27504 Address • Email Address � I 1 21144 Signature of /C. tractor/Officer(s) of Corporation License # Mechanical /HVAC Contractor Information Description of Work New Construction Stephenson HVAC 919 329 - 0686 Mechanical Contractor's Company Name Telephone 343 Shipwash Dr. Garner, NC 27529 Address Email Address 1 4/I 18644 6f Signature Owner /Contractor /Officer(s) of Corporation License # Plumbing Contractor Information Description of Work New Construction # Baths Thorton's Plumbing 919 669 - 8655 Plumbing Contractors Company Name Telephone 3160 - A Omar Rd. Clayton, NC Adlress � 2 .... -}�� Email Address �d / J mail Signature of Ov)ner /Contractor /Officer(s) of Corporation License # I Insulation Contractor Information Tatum Insulation 919 661 -0999 Insulation Contractor's 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 Technician to determine if you qualify for permit under Owners 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? _ 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 if 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 and all changes. EXPIRE! PERMIT FEES - 6 Months to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee is as p current ee hedule. / Sig lure of Owner /Contractor /Officer(s) of Corporation Date Affidavit for Worker's Compensation N.C.G.S. 87 -14 The undersigned applicant being the: J 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 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 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 Nam Wynn Construction. Inc. A -7 Sign w Ti 6 Date: / r // • i 1/ •