BUILDING APP 09f0o111 Application#
Harnett County Central Permitting
teach section below to be Med out PO Box 05 Wbngton NC 27646
by whomeversdo performing work 810 003 7626 Fax 010 893 2793 www hemelt orglpemida
Must be owner or hoensed
contractor Address company Apolication for Residential Build=and Trades Permit
name&phone must match !!,,..__ �^
Owners Name (/1��rnL.L� YL0>wt Date ll VA fl
Site Address .q86 04-1,44,i (Q.l��. 1 • - PhoneIQ4QS S A,
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Directions to job site from Edlington Oel e{/.00 I C Yntti�SI• .÷111416/45 1 Sf r
(r.(gip. aya_i 5. 4olit Auk m_Aiwa CYZ -
__C,04•ritl44 OYt ILSjiI- eztA411240 At ins •
Subdivision _ C L- ii .-____ Lot ...
Description of Proposed Work 51:1/- #of Bedrooms 3
Heated SF Vito Unheated SF (4v) Finished Bonus Room', Crawl Space Slab
General Contractor Information
4.01%11--1•L 33U'M.- OG?
Building Contractors Company Name Telephone
Xre Gti.. r. .i ,. ' , t 1...Ai0 1-riV4ZatilaiiLiorelaihorntS.GA
dress 2714 la Email Address
License#
• _ = • ". • 1 _ =7:r i • III • I
Description of Work ■ i 4:7fTI Service Size e. -mpa T-Pole✓ Yes No
W'3 a14.550rt541
Electrical Contractors Company Name Telephone
CtiekttarN r.c.0 WI tealV-lige-401
Address Email Addreile
!4721
License#
MhanicaUHVAC Contractor Information
Description of Work.NLritnct A I r to
el) r-4-Ate 3.3(04‘i i• 117)
Mechanical Contractors Company Name Telephone
aVaratititgram
Address Ema Address
gLIK
License#
Plumbing Contractor Info/Ireton
Desc4ption of Work 2fuVonkil il -1.19ia(( #Baths
c to PlUsMn aIq 96 '433
Plumbing Contractors Company Name Telephone
3tun 4 0tv60En.O.Ith2:157?) Ema A'dre •n+e.yin� ry�,t�.r.
Address G0U"l
ZZE#
License
Insulation Contractor Information
ILt . 5l4.Su(al1OL1 a,ct.18 . ,
Insulation 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 questions then see a Pernik Technician to determine If you qualify for permit under Owners Exemption.
Questionnaire per Q.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 that I affirm that I have obtained ell listed contractors
permission to obtain these permits and If any 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
anyvist nges.
EXP 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.
�• 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),firms)or corporation(s)performing the work
set forth in the permit:
1 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 Name:WJH,L.t,C
Sign w/Title: R"' Date:10/5/2017
RF:SIDF.M rlAi..RUILDINO APPLICATION 2 .; 04/I 1