BUILDING whomever performing work. Must be owner Application #
or licensed contractor. Address, company
name & phone must match information on Hamett County Central Permitting
license. PO Box 65 Lillington, NC 27546
910 -893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
Application for Residential Building and Trades Permit
Owner's Name: /4 /Ipso eex i Date:
Site Address: ;5 Co (6 n raLV-L5S D 2 Phone: ¶ yy1''i t,
5
Directions to job site from Lillington: hal 27 5 T L oM 4'c aseb. on Pit b
Subdivision: etribrttai I Lot: A
Description of Proposed Work: Alto) Cans ew dpi, #Bedrooms: 3
Heated SF IWO Unheated SF ,c Finished Rec Room? /-r-6 ar ) Slab ( )
/ /j General Contractor Information
l tot Kn to ,:.5n.� 14 hone s / Le. ¶I O -yni - 5506
Building Cbntractor's Company Name Telephone
� I 1 12,.,.,x.• t }rut 5�:-k. 3on F e #r ✓; Ile (C7 W
Addr ss e t / "`I License #
Must sign & fill out second page
i gnature f Owner/Contractor/Officer(s) of Corporation
Electrical Permit Information
Description of Work n3r.1 /nnS+r“04 -:r.- Service Size: 2 Amps TPole o
5 - iZ?A 0 1:'I 41.9- 373- 2`f5f3
Electrical Contrattor's Company Name Telephone
qsy 1.," L.ve.i gonA / Sir V..) :I 1�1G O L4
A•dr-ss / ) License#
f_a nas
Si nature of Officer(s) of Corporation
Mechanical /HVAC Permit Information
Description of Work NC..t /n..,p +va 4 Jo.-.
All AI44asal Nre}i.+ t 4?r eon - 214 - 95B H
Mechanical Contractor's Co Name Telephone
` 1 01 5 Obi Fa.. ((¢ ton.K Fa, 1 o $ .i r' I l 7g3fq L N 3 410.55
Address License #
Signature of Officer(s) of Corporation
Plumbing Permit Information
Description of Work NIcv- /., c l-..,. r4:n. -. # Baths 2.0
Doll N.. flu,..424.1 silo -et 8 - - 863
Plumbing Contractor's Company Name Telephone
761 Do(. .Iwvn rr∎tont Dr; ✓r / Fµ, -14 ✓;I - . Di- . 2 04 4P I
A ss n' 1 License #
J� 1 p1 1 CJu v.�
Signature of Officer(s) of Corporation
Insulation Permit Information
'(r ;- /; {- . Prol..1 -s go- 237 .- 0 4 157
Insulation Contractor's Corr Name & Address Telephone
8/21/08
Homeowners Applying to Build Their Own Home
Please answer the following questions than see a Pernik 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. 1 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 Hamett County Central Permitting Department of
any and all changes.
EXPI D PERMIT F i ; 8 Months to 2 years permit reissue fee is $150.00. After 2 years re -issue fee
is e r current fee t ,liul
•
Signature Owner/ •ntractorlOkicer(s) of Corporation Date
r
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The u ndersigned 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. ` J L
'!
Comps
ompany or N�aine: V , e Jf 1 /flan /' r� 5
Sign w/Title: /g i MA47 sec- Date:_ Z. 1 11
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