BUILDING 09/09/11 Application#
Harnett County Central Permitting 1'7 - s- H a a q I
PO Box 65 Lillington NC 27546
Each section below to be filled out 910 893 7525 Fax 910 893 2793 www harnett org/permtts
by whomever parforming work
Must be owner or licensed
convector Address company Application for Residential Building and Trades Permit
name&phone must match I
Owners Name Ri( k4rr `y teb.6(LG LAML.I Date I2-1 -11
Site Address aaq Elam?01 Lart0, AtlaiVr Phone R19- 33%-O 97 VI
Directions to job site from Lillington yo n' 124— 6 2 /s-4 4
Subdivision Lot
Description of Proposed Work pf el-) 5 Fp #of Bedroom", 3
Heated SF 1837 Unheated SF 650 Finished Bonus Room'r ttd Crawl Space ✓ Slab
General Contractor Information
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Building Contractors Company Name Telephone
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Address Email Address
License #
Electrical Contractor Information
Description of Work W'et N¢••_) fiat CO Service Size tad Amps T-Pole VYes_No
Jason tt Pope E(ed-Ir,caq10/- cz6- 0837
Electrical Contractors Company Name Telephone
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Address ' Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work WE ACL !3L'3 +44t(.E
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Mechanical Contractor s'CoImpany Name Telephone
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Address Email Address
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License#
p Plumbing Contractor Information
Description of Work rlu NluJ k. -t #Baths
G-,1‘19(4.- T Iu0,4b,yt Ca 9 to •s6, 7 0 3rd
Plumbing Contractors Compan' Name Telephone
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Address I Email Address
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Licensee##
Insulation Contractor Information
h4wla-H Zhu 5-16 a. nietkvale Rd (ZeLi No Gild -712-- macs
Insulation Contractors Company Name&Address f 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 Harnett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that pv signing below I have obtained all subcontractors
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 Harnett County Central Permitting Department of
any and all changes
EXPIRED PERMIT 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
:::0117 AA-1- r 1(-36-17
Signal re of Ominer/Contractor/Officer(s)of Corporation
oration Date
Affidavit for Worker's Compensation NC 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 for{h in the permit
V/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
V 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 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 /� -rte.
Company or Name re-kat/AA (,BNS 1 lr^'Z -f N G
Signw/Title �� At 4-- t- Fµ W Date If• 3d-17
DO NOT REMOVE!
D et all c: Appointment of Lien Agent Filed on. Nr30/2017
Entry If 763Il4 initially flied by
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liers and subcontractor'
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O.n.r Information Det.of First Furnishing
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