BUILDING APP 09109/11
Application#
Harnett County Central Permitting
Each soden below to be Med outPO Box 05 talhngton NC 27640
by whomever performing work 910 893 7626 Fax®10898 2793 www hamett orglpemnKe
Must be owner or licensed
contractor Address company /loolloation for Residential Building and Trades Perm
name&phone must match !�
Owner s Name aideaviunit.L4110 Date ll Vol f
Site Address 3E6. &j.i4v /41/L De• • Phone
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Directions to job site from Lillington ilL041. W. Oil f....4-rnsvi•sk ,, Wt s I S*5L.
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Subdivision _ (i5- _,d---86.441010)yl ei . — Lot
Description of Proposed Work S�� �n22.- #of Bedrooms 3
Heated SF 240 i (4O 0 Unheated SF Finished Bonus Room'? 4) Crawl Space Slab
General Contractor lnformptton
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Building Contractors Company Name Telephone
dress taardtiaCor AU Sit,--W C4rZ�L '0 <0142' Z d t�d�h�Oi'I'1{,5.Ctoi
2,14 Email Address
License#
Description of Work .a i '.TTI Service Size a •mps T-Pole✓ Yes_No
(u-.3 414.5,5o.1 541
Electrical Contractors Company Name Telephone
Address
81,04.1tun
Email Addle o-1 Loy
ss
1l;221
License#
M hanical/HVAC Contractor Information
Description of Work.1•4611A1 AI r
0.0M. 'ar4-Ali' • 334'7aq•415?)
Mechanical Contractors Company Name Telephone
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Address Ema Address
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License#
Plumbing Contractor Information
Description of Work PLU.4MiOIt11 C j( #Baths
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Plumbing Contractors Company Name Telephone
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Address
Email Addres CO"
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License#
)nsulatton Contractor information
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Insu anon 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 Permit 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? I 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? I 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 all listed contractors
permission to obtain these permits 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 certify It is my responsibility to notify the Harnett County Central Permitting Department of
any lli�d nges.
EXPIFIED►�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.
' l 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 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,I l C
Sign w/Titie: �"°` Date:10/5/2017
PFSIDF+'I(IAI BUILDING APF LICATI3N 2 �; 04,I