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wars Address company Application for ResMenbal Buddma and Trades Perrin(
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Owners Name //// , /E�.✓/Na 4fft7 ,GINS Dater":
Site Address /7wr� 27 EAST �'_aCrY /It st7S.3/Phone f s - LD
Doectons to rob site from Langton /mein 27,41ter C n 447 tenni' 7 nen
etC 711.s.c '4rJ/ t nodes , ora- /nfic.- o. )/seer:
Subdivision 41/4 Lot L sat ac
Desenpbon of Proposed Work Akfw5n.Jbca l Zs>� f#W of Bedrooms 5
Heated SF Unheated SF polished Bonus�m'N/O Crawl Space _Slab
General Contractor Mfcnn�oQ
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Eluddmg Contractors Company N / Telephone
69002 /t'. serosa /PC 621-24/ itafave ooca,...
Address el Address
7999s-
License#
Electrical Contractor Infonnaboi
Desch on of WaltJ'; ��/rca-' Go•-5,tce flor-/ servicesize Mips T-Poe _L--1-1---;_No
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aecuEal Contractors Company Barna Telephone
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7974 ces/.!/� .moi) .te
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bsechamcal/HVAC Contractor Information
Destr ion of Walt .r1.�`Z.-ce,%reizo cJ
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License*
er Insulation Contractor Infonnsbon
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Insufatan Contractor a Company Name I Address.! eljphone
'NOTE General Contractor must fa 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 canfam to the regulations in the &rldsg Electrical Plumbing and
Mechanical codes and the Harnett County Zonrg Ordinance I state the nformahon on the above
contractors as correct as known to me and thatpv signing below I have obtained all subcontractors
pernrsaen to obtan these hermits and if ggy changes ocar nckrding lusted contractors site plan
number of bedrooms buidng and trade plans Envhronmentel Hearth pend changes or proposed use
changes I certify it is my responsibady to nobly the Harnett County Central Permitting Department of
any and an changes
EXPIRED PERMIT FEES-S Months to 2 years permit re-issue fee Is$150 00 After 2 years re-ssue fee
Is as per schedule
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(s) orporation Date
Affidavit for Worker's Compensation N C G S 87-14
The and eppknd being the —
General Contractor Owner Officer/Agent of the Contractor or On
Do hereby confirm under penalties of perjury tat the person(s) erm(s)or caporation(s)perfonnng 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
Has no more than two(2)employees and no subcontractors
While working on the prgect for which this permit is sought it Is understood that the Central Permitting
Department issuing the permt may requre certificates of coverage ofworker s compensation insurance poor
to issuance of the permit and at any tine dung the permitted work from any person firm or corporabm
carrying out the work ,,,�// ,�j;
Company or Name 2 4 Y c-..4raINiC / r,LiCtlS
Sign vat .ilii i-rte Date - .9y/r