BUILDING R r -taco sechcn below to be Blind out ,vppllcaoon3
Harnett County Central PermiNinq
by 4nomever performing work --
Mustbeownerorlicenrtl PO Box 65 Lnlrnglon,NC 27546 /�y �/
name&phtor. Address,ilob company V/��o- 75 Fax 910-B93-2i ora.+harettorIe It{ / —SG.0/1� / liL
contrname&phone must match - l/ Wif- 4' 3 D� /.
Application for Residential ZBuilding and Trades Permit- �� / /
Owner's Name: �� � /7/1117
(!1 /7 z N �/18
// C Date: ""ff" ll
Site Addres r •• /33 , 3/ _3 6-
/v Phone: 0-iy
Dir- -- s''oh sit- fr..• Ii/ .n:-
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PC. "' i /�. • iii;
i
tii/L/.�� H. i // //iii
Subdnnsion: - _ A.'%f.., r �
� S �� "�
Lot: /3 3
Description of Proposed Work: ' A 5F
# fir/ 3
Heated SF:Zc(.4 Unheated SR /1- Finished Bonus Room? Bedrooms: T�
Crawl Space: Slab:
� �/ � / General Contractor Information
Building �ctols Company Elam
A290- Cont£ 7�7 i(,id/ //� apd Telephone '�l� ��// � / /
�O,� � oanididrss 2C:1P11r..rr/�i/,F//GT
Ak
all
JAddress //
Sign--- e of t er(s) of Corporation _.<7 e#
Elec lea Con ractor Information
Desc '•tion of Work s - a" 0�i. Service Size'. 4 Amps T-Pole:
/ _ ✓ Yes No
Po 9/9- I/99-,5389
Electrical Contractor's Company Name
.S .41:
t Telephone
Addre
Emai Address
•
Signature of Owner/Cont--;,,.a..
ractor! r(s)of Corporation �a�7-/�
License#
Mechanical/HVAC Contractor lnfarmation/ /'
De ippon of, ark ((eft/l+/ .5244- am �e(�.- SIWet, �� C _
,- ' : Y - ' r A ! /' 9/0 -. -/,1(0
rilecn-C cal Lontragec srC�o/ pan/' amt
A� �aX /�// C P Teleph/" .
Addre 9 ,—VA �l'd/L3
All° "Email Address
... i,<..,7,"<—_ 0106/61
Signature >Ti on a ort er(s) of Corporation
License x.
/ Plumbin. Contractor Information
Description of Work/Y' -a - - #Baths 3
` G/b ve r-
oftg
WO-J-.3/-3///
Plumbino Contractors Camneov Name
Telephone
Add
Em=ir Artrira[c
Signahire of /Contr or/Officer(s) of Corporation License#
Insulation Con ractor Information
7•17:/# .' --ate,411.' 4/1 e,sotr 9/0-is -f8sif
Insulation C actors Company Name&Address e Telephone
Address'? 4r
'NOTE: General Contractor must fill out and sign the second page of this application.
I hereby certify that 1 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 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
EXPERMIT FEES-6 Mon to 2 year •ermit re-issue fee is 5150 00 After 2 years re-issue fee
s per cu ent fee schedule
,01
Signature of Owner,ntractor/Off.A 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
1----1-las 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
Y 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�wworrkkfffrroomm a/,ny person firm or corporation
carrying out the work / /F�
ZecCompany oriersC
sign w tie - / / �r Date
/,47// /