BUILDING Application # JDsate2s
'Each section below must be filled out by Harnett County Central Permitting
whoever is performing the work. Must be y g
owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546
company name & phone must match
910-893-7525 Fax 910-893-2793 www.harnett.org /permits ._.
information on state license. COMMERCIAL
/ Application for Building and Trades Permit
Owner's Name: ; u 1 5 9 / e Date: _ f -' /O
Site Address: 3 iii f 6 /f, 1"l, (a 1c. �✓l -, - t mn •'a4.., �✓_' Phone: C// 9 - Y , f) f _
Directions to job site from Lillington: 4'C 2. 7 #0..✓a✓A Ca .., vrflin, _ 6,; L.- le/ u ,,
64i /c/ /4A 5 / 61 Jo /V( A 6-o 4.Q 74 / .d Li .v
Tyr- n- te (1- H r l id Ce
Subdivision: , p1 I. Lot:
Description of Proposed Work: / pvc- C , ".%# /mi M.c .1i; fd c,4,q..c
Heated SF /7 Y Unheated SF
General Contractor information: Building Cost $
S 0 ,t 49 - »7 $ C) .fr,l 9/1- y f - )) .2-
Building Contractors Company Name Telephone
5 . /V rl. (.. ai /,, t,
Addres E ppil Addr ss
L
Sign a or° - ontractor/Offcer(s)-of•Corporation L' ense o 0
EI cal Contract &Iiifo Electrical Cost $
Description of Work 1 11.hrpt a !-LL 0 Service Size: 10 Amps #T -Poles 14
i , ` k lt/,9 - R w/e are-6 .;yy EJedd c, 010 2-Si -L137
Electrical ntractor's Company Na e Telephone
all rufazI ).Ro-c-. R4tercf \22A 10i, d'0.5
Addr s Email Address
Signature o Owner /Contractor / Officer(s) of Corporation Licen e #
Mechanical Contractor Information: Mechanical Cost $
De cription • Work # Units
Matto ' /. ,' Otte „,1:65
' rchanic -1 / C�ontr ctor's Co�an Na a Telephone
V 1)r2�` dd) Nei C AI - yy � . ii 111/SI 'Y .4 a y.-
Addr EmafrA r s
S' ra ura 9 O ne Contractor/Officer(s) of Corporation ' cense #
Plumbing Contractor Information: Plumbing Cost Sr, (2 c,
De of Work # Baths
.1 ✓4.4_1 4 ( �L v&.. 77') - yc).',S
Plumbing Contractor's Company Nine Telephone
it'/) ) /-v g 7 . 1 Car,v,I)or 4 ( 2 » 2 7
Ad ress Email Address re_
2 S' nature of Owner /Contractor /Officer(s) of Corporation License # 7 /
Insulation Contractor Information
Insulation Contractor's Company Name & Address Telephone
•NOTE: General Contractor must fill out and sign the second page of this application
Commercial Building Application 1 el 2 8,10
Sprinkler Contractor Information
Sprinkler Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Fire Alarm Contractor Information
Fire Alarm Contractor's Company Name Telephone
Address Email Address
Signature of Officer(s) of Corporation License #
Driveway Access - NC Department of Transportation Driveway Access/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 if my 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 charged at full price per current fee schedule.
/ 2— i0 �
Signature of Owner /Contrac or/ er(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.
L- **" ...- 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. / CA
L€ or Nam Jeer.. / .1, rill Y C / AL€ re 1
Sign w /Title: b G re^ ,.JC o.-s (G Ja Pere k r+.e 4.I Date: 1? -e-/ o
A. S e v
Commercial Building Application 2 of 2 3/10
FION :earthworks FAX NO. :910- 947 -1130 Jan. 26 2011 03:43 P2
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