BUILDING Application# if 1 ri 37
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546
•Each section below to be filled out
910-893-7525 Fax 910-893-2793 www.hamett.orglpermits
by whomever performing work.
Must be owner or licensed
contractor. Address,company Application for Residential Building and Trades Permit
name 8 phone must match I , I , '
•
Owner's Name: A -D; O. W�1.yr1 K Ills Date: 520//
Site Address: 170 Aspen Lane L1L4il5 Si KC PhoJn/e 4'l10 o S8yr1I
Directions to job site from Lillington: 2.(0 /L&r'h 'Utes RI/sI 4 *raft 014' 2iJ ..
b'o'lakit, SClwo�/ {urn /'f# 4 MIA- Croce rad 71-071-021i2lilt Loln riff1066/lJt SIOm» �. F An
Subdivision: &Mink^"' •
! LL Lot:
Description of Proposed Work: 411$17 bare Orr/ #of Bedrooms: L
t
Heated SF: 626 Unheated SF: 2-IC Finished Bonus Room? Crawl Space: )'r Slab:
General Contractor Information
wor(C gone b5 Own9/o —gro—S99/
Building Contractors Company Name I Telephone p
Tnsn, omorl2 ChgrryrnS
Address Email Address
License#
Electrical Contractor Information
Description of Work (thee MOM it, LasfDP Service Size: Amps T-Pole:_Yes No
Work hat ter owner 4"se
Electrical Contractor's Compaq Name Telephone
Address Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work /
Ctbr/C doneOowner
-
Mechanical Contractor's Company Nafne Telephone
Address Email Address
License#
//11 / )PPlumbinq Contractor Information
Description of Work 4,11 (Aa7Nruon #Baths
(pork dcL% Own Cr-
Plumbing Contractor's Company Nkme Telephone
Address Email Address
License#
Insulation Contractor Information
work clone b4 owner
Insulation Contractor's Company Name&Address Telephone
`NOTE: General Contractor I owner 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 by signing below I have obtained all subcontractors
permission to obtain these permits and if y 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.
-ii��
2MO/8 •
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
cthemselves.
ovennHas 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 o�SlgName r
�, n w/Title:e: Date:///� X9
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