BUILDING 1- Application # C 7 52' - /E 5"...* / K e East sectio
to be filled out Harnett County Central Permitting
by Must be owner whomever performing
or licensed forming work. PO Box 85 L.illingtcn, NC 27548
contractor.
M ow Redress, , company 910 - 893-7525 Fax 910 -893 -2793 wenv .narrwttorgl p ermits
name a
name it _7 pnone most match A
Application for Residential Building and Trades Permit
Owner's Name: 4=r .; a -e . K a er < , r -: < e ♦s' r _ Date: 2 - - 2 S /
Site Address: _ — Phone:
Directions to job site from Liilington: hes y ex - 7 •.« e S - 7 - 7 . ..1 - 77.....
1' r71 / ; it fa4 / , 7 e,1 Trfzii
Subdivision: t r'. ni /r• / 7 Lot: 1/ V
Description of Proposed Work: ,c-' e t- ,xic r- ! — # of Bedrooms: -
Heated SF: /Y Unheated SF: Ceti Finished Bonus Room? ye./ Crawl Space: -- _
General Contractor information
et /T eC P .a1 7- fie in (71t
Building Contractor's Cornpany Name Telephone
' S YC
F. 4 7 (' � ��tl iia v (''tJ .L, /� /r ts'ir �.. . L:l �
Address Email Address
�'_ 1 / 'IA E
Signature of Owner /Contra oct rlOffEer(s) of Corporation License #
—_ - - - - -- - Electrical Permit Information
Description of Work - Al c 44' i/e �aJc Service Size: , 2_r c i Amps TPole: yes /no
z'm POP fJafr tic tpo —.1L45 - 7
Electrical Contractor's Company Narne Telephone
f lit 0 I taint-oft 0•., R/,7:1
Address License #
1 m
Signadur o Officer(s) of Cerpo anon Mechanical Permit Information
Description of Work /1/ e L"- le- 4. a / c --
.7ariiJL Le.:/n14r /9 /r `2/9 333 4
Mechanical Contractor's Company Nanie Telephone
Z1, al . ___ . U .: 70 w CJa yt /`G' J 17. 11, cense 90 7 7
Address
c am.( C �4-Ad �f
Signature of Offi r(s) of C rporation Plumbing Permit Information
/es t% a« Jr ,_# Baths
Description of Work Jt f
B f/ ft, r# « 77
Trek in r c � ✓/i n Se," �✓ /u��7 -ern Telephone
Plumbing Contractor's Company Name ,,
lSV6___,� /6/( S
_Lit 96' eta /'/�' 0 v< / //l /is.", �� #
Address/ License
nature of Officer(s)' orporation
s Insulation Permit Information
44-w /,_ a 7 , i _ --
Insulation Contractor's Company Name 8 Address
Telephone
•NOTE: General Contractor must fill out and sign the second page of this application.
D 7—,Sc'' — /6' Sa/ 'P
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if you qualify for permit under Owners Exemption.
Questionnaire per G.S. 87 -14 Regulations as to Issue of Building Permits (Memo available upon request)
1. Do you own the land on which this building will be constructed? _ Yes ,
2. Have you hired or intend to hire an individual to superintend and
manage construction of the project? — Yes �o
3. Do you intend to directly control & supervise construction activities? No
4. Do you intend to schedule, contract, or directly pay for all phases of
construction work to be done? rites No
5. Do you intend to personally occupy the building for at least 12 consecutive
months following completion of construction and do you understand that if
you do not do so, it creates the presumption under law that you fraudulently
secured the 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 cm 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.
— ,sus%
Signature of Owner /Contractor / fficer(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.
_ as 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 Name: etcre c 'fie' " S
Sign w/Title:/1' —_ —✓� ! .I — Date: 7—. I /
Residential Building Application 2 of 2 10f 10