DOCUMENTS Application# \ 1. 561-1"S3qQ.
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.harnett.orglperrnits
by whomever performing work.
Must he owner or licensed
contractor. Address,company Application for Residential Building and Trades Permit
name&phone must match
Owner's Name: Tefer>•.i + Sawiniars.. YB.C-IID 1+ Date: 5 —8-11
Site Address: /35 m ?/JcY Racial PTAn22833`/Phone: 9'/0.89/'5`/65
Directions to job site from Lillington:/11a) Z1 gas r 1.41- or. T3odr5 c ho rc.i R
ort to soler if-t- /four< /re 4
Subdivision: Lot:
Description of Proposed Work: IVeu)- F'la w5 e #of Bedrooms: 3
Heated SFaaS2 Unheated SF: /%9/] Finished Bonus Room? 91Z Crawl Space: Slab:
General Contractor Information
SStcG-c.vr+.( er.rr..ta,tlar•sNc 9/o-PJ9/-5v‘ 5
Building Contractor's Company Name Telephone
Po. ,Box 136rf NA,/ /t{•C. 2Q33rf 704,01e 5kyn /Contywehnrs.Cosy
Address Email Address
-763a Yee
License#
'1 Electrical Contractor Information
N
Description of Work tu) Service Size:2oo Amps T-Pole: Yes_No
$. »t B Pe C/ecJn to / n1/O -840 - 3455
Electrical Contractor's Company Name Telephone
Yo9c1a..A.'» s 4 5anGid z733o
Address Email Address
a/12c—L
License#
Mechanical/HVAC Contractor Information
Description of Work lucu/
(faro(rYw. Lrr-n )4-1 41Q- SSo -ZY42—
Mechanical Contractor's Company Name Telephone
2/2 LiI /4419 la Bt srwt C/al/tw„ /4-C'
Address 27520 Email Address
age 711
License#
Plumbing Contractor Information
Description of Work IQtu/ #Baths 3 �Z
2 5 c G,-tbs.+ PI4„ tp; 9/o-Z/v-/27tf
Plumbing Contractor's Company Name Telephone
7- , #C, 12044l .Dann N-C
Address Email Address
/o9a9
License#
Insulation Contractor Information
eQnt/Iei/ors/ -1,0514 4%on Qt4.2o7 -7813
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 mi 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.
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.�
in7/1•I7ffc,,/ 0tr $-0$-/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.
t/ 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.
Company or Naamf'�j itt--e-"--r"/•'0. + �""5
Sign w/Title: %wa`^'� H'"464 — fo%ir•✓ Date: S—Os-/g-
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 05107/2018
Entry #: 846738 Initially flied by: shanelmc
Designated Lien Agent Project Property
Print & Post
Instars Title Insurance Company Single family house built per plan and scopes
135 Miller rd Thum nc 28334
on ae wlme Dunn NC 28334
Add.19 W 11argell St Sulu naieurn,Nt Harnen Caunry Is';1
29(p1
Er, ..°
Plume:Ein.(00.738.4 Properly Type Contraeton:
Fn.9'3-459-5231 Please post this notice on the Job Site.
1-2 Family Dwelling Suppllennd Sebtonfntlon:
Scan this image with your man phone to
view this tiling.You can thou file a Notice
to Lien Agent for this project
Ogino Information Date of First Furnishing
Mellott 0601/2018
135 Miller road
Dunn. NC 21030
United States
Email:ShanKFegeneralcontracmrscoIn
Phone:910-891-5465
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