BUILDING 09109/11 Application#
Harnett County Central Permitting
Each eecDon bebwbbe Med outPO Box 86 Winton NC 27548
by whomever a below to worts 9108937626 Fax 910 www harmh ororpermes
Must be owner or licensed
oonbadv Address canteen ADolulatIon for Residential Burldma and Trades Penni
name 6 phone must match
Owners Name /a,Qr C//I ��7 Date % /7//7
Site Address / 72 V1 y � nh,r�l� Phone 9/ to 7/`)/
Directions to pi)site from Lillington
7 T97/ 6, m-rf e J
tOnti .�J
Subdivision O //�� Lot
Descnpuon of Proposed Work 4 ZaRo4 07 6 Bedrooms
Heated SF Unheated SF F Bonus Rdbm9_Crawl Space _Slab
�
C
6411e/icat/ /nLer Jul r 67/0—tn)—//9/
Building Cont�rgtor sc�om"pany NameTelephone
/36/ t i/de f0 a A'acs amert7r1 (r'O Q kner cam
Address E ll ss
�9 5-S15�
License#
cledtncal Contractor Information
Description of Work Service Size _Amps T-Pole _Yes_No
Electrical Contractors Company Name Telephone
Address Email Address
License#
Mechanical/11VAC Contractor Information
Description of Work
Mechanical Contractors Company Name Telephone
Address Email Address
License#
Plumbina Contractor Information
Description of Work #Baths
Plumbing Contractors Company Name Telephone
Address Email Address
License#
Insulation Contractor Information
Insulation Contractors Company Name&Address Telephone
*NOTE General Contractor must fill out and sign the second paps of this application
I hereby certify that I have the authonty to make necessary application that the application is correct
and that-the construction will conform to the regulations in the Buckling Electncal Plumbing end
Mechanical codes and the Harnett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that Dv stamna below I hays obtained all subcontractors
permission to obtain then permits and if pay changes occur including listed contractors site plan
number of bedrooms building and trade plans Environmental Health perms changes or proposed use
changes I certify it is my responsibility to notify the Harnett County Central Permitting Department of
Eny 'a
EXPIRED anges
P RMITMR FEES-8 Months to 2 years • it re-issue fee is E150 00 After 2 B re-issue fee
is as per cu nt fee schedule
L._Engl i of Owner/Contra,. . •.: cer(s)of Co ..Won Date
Affidavit for Worker's Compensation NC G S 87-14
The undersigned applicant being the
1 General Contractor Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of penury 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
Hatt 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 projectfar which this permit is sought d as understood that the Central Permitting
Department issuing tpe"perm ay require certificates of coverage of workers compensation insurance prior
to issuance of the permit and any time dunng the permitted m any person firm or corporation
carrying out the/Work
Company or time
Sign w/1Ne �fP Date 7 I&