BUILDING 09/09111 Application#
Harnett County Central Permitting l - C- "4 a K / 2
PO Box 65 Lillington NC 27508
Each section below to be filled out 910 893 7525 Fax 910 893 2793 waw hamett orglpermtts
by whomever performing work
Must be owner or licensed
contractor Address company Application for Residential Building and Trades Permit
name&phone must match
Owners Named/pµ0 Snit woo d 6.44 Date /-Z[ -('
Site Address 11521 Prom.At NS A t&A Phone 1/0 • S2f/ 2^ /h-3 (
Directions to lob site from Lillington
1&Ik ' 1 11 Maus 4-o NC 5(1 #19455 TR-
59 Its
(. 3 A-t. Li, T1 ft LI._ 6l`i: A. 2rfi - 5n Ylu M. (t
Subdivision Lot p to ro)
Description of Proposed Work t'1 Q 4 S F l) #of Bedrooms / 4
Heated SF 121111 Unheated SF (D tel Finished Bonus Room's /id Crawl Space ✓Slab
General Contractor Information
FrEED&K OertSfenctr¢; 75.4c_ q1 C- Sha- ! a 3/
Building Contractors Company Name Telephone
PP io 4 (ooS -pg A n NC- 28 33 5 r{arfa re onsf✓uc}ws. co M
Address Email Address
lisyo
License#
Electrical Contractor Information
Description of Work Wier Neral 1*44 LQ Service Size Z14) Amps T-Pole VYes No
-Trion it Pope Cled{r.cA CcnfT .eiey- 4/9- 8id- 0 £! 37
Electrical Contractors Company Name Telephone
81 6eaAr Cra Dr perm NC ZI33'4eVtcir cal@kat a 1. G M
Address Email Address
Sar5,114 - ut-
License#
Mechanical/HVAC Contractor Information
Description of Work Hi/At- 10140-) V7413.9.-
-StIA4-1/c.-kin/c, 4- kr Ike, '91C-M7 -561 (
Mechanical Contractor s'Company Name Telephone
7 k Tnrlit m Rel , t�n/in NL lk3V-1 `Lamhtfsc )Centcati k.n 6)-
Address
)Address Enact Address
( 71#
License#
plumbing Contractor Information
Description of Work -PN,n# uit- f1.N<St #Baths
G,-,t\DV+ -N4Mbi1-yCo 9 to .51a 1 Ca 30 1
Plumbing Contractors Compan4 Name Telephone
Oen Twa-tl PA f v' NC ? 833 `l jrcrj in}vslar. At1-
Address 7 Email Address
La
Licensee##
Insulation Contractor Information
;�-n4d Ch,j Inc 510 V. role*Mt. RA RaL,yh Pi- 411'1 -712-- q000
Insulation Contractors Company Name&Address ' 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 stale the information on the above
contractors is correct as known to me and that qv sum na below I have obtained all subcontractors
permission to obtain these permits and if psy 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
M-4 (A uJ� f_ z f I r
Signaturef 0 r/Con ractor/Officer(s)of Corporation 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 forth in the permit
b' 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
vias 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 d 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 1 /� I
Company or Name F 4'4 - k15*S}fscj-cqi Aid,
Sign wattle - 113-1L )'t-7-4.- R( /'wid, / Y, Date / ^ Z /