BUILDING APP 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 shiniest below I have obtained all subcontractors
permission to obtain these Dermas and if e�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 anent fee schedule.
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SIgnatu of er7Con r/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87-14
The undeJslgned applicant being the:
General Contractor V Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s),firn(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. /
Has one(1)or more subcontractors(s)who has their own policy of workers'compensation insurance
covethemselves.
Has no mare 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:
iw(Title;��C4` 1rie: R)a jX