DOCUMENTS/RECEIPT ,4pp 2 fl Db 4 qboss2-
Hamett County Central Permitting /
_ PO Sox 65 Moan,NC 27546
Tarboro.Number 910-893-4759
Application for Building andTrade Permit
Owner's Name: 4-14, r3.i14,,_ ,c�.,r/dvs - -.7-4,_ Date:
Address: 7a- Dotrloor CA- .4.ijes 'in- ?73G/ Phone: 9/5- le-?7- YGdq
Directions to job site: _-_,.
-, n/ - a-, <,� k!-a,1. - 2...1-'1/ .n
CoVeSki-L- . - - efk DA res ley , - Lo •Thti .91
Subdivision: ✓Sty ger,- Mt-,Pr' Lot: al-
Co�nnstruction Two: (Pleate Check) Building Use:(Please Check)
gNew ,Residential
_Renovation _Modular
_Addition _Commercial
_Moved House Multi-Family
Other �
Description of Proposed Work: 5. ✓ 11- - t.r+. l/
Total Project Cost /a of 'Cf-' f
Building Permit Information
Heated SF /145 Crawl Space A Building Construction Cost$ /7 0 Dc B
Unheated SF �o Slab AAcres Disturbed 70 Stories I
.- CL-(_,r,,./lo, £)L. l e)erS -S t . 9'/9- 5'oT> - •746.2•5?-
Building
<G2•S`Building Contractor's Company Name Telephone
7a t ue1 /cot"- 00 e4�,er d� .02,... / 4/7s'o7
Address //� License#
Signature of of Corporation
Electrical Permit information
Description of Work�r , e-e-•-) Electrical Cost$
TS Pole: Yes Vr. No() Underground '( Overheard ()
Permanent Service: Underground, verhead() Service Size: SOC Amps
.bei..,. afY.4_, 2-1-c- 9/5--Gd.,S- ooc 3
Electrical Contractor's Company Name Telephone
3753 .2 -tc,v.ic 1-.-J. .=.�,.rJa.,, X9832. -L
Address License#
,C/ ea.✓ 6
Signature of Officer(s)of Corporation
� II Mechanical Permit Informatioq
Description of Work N Cts
Number of Units Type System FSP Mechanical Cost$
Mechanical Contractor's Company Name Telephone
S3/3. ✓S r/i, 7v 2.,s G71-4i ,✓c_ a7sgo /0-90 77
Address <- �� License#
Signature of Offi 4 r(s)of Corporation
Plumbing Permit Information
Description of Work Aiem--5
Number of Baths Plumbing Cost$
i.e. Gr 't.., .:J/ Y^`' - 9/9-5,'92/ - s55a
Plumbing Contractor's Company Name Telephone
Ar 80-v 7tej &,k,., 4/1 6175'0 ' ,Ac7?SS7
Address, License#
GC 6/D._'! 5 aye.
Signature of Oficer(s)of Corporation
' ,c Insulation Permit Information
Residential (y-6her () Not Required ()
-rs✓irf's _rya c. - %/zSL,/,✓L 9/S- 77a-7./,u
Insulation Contraaoris Company Name Address- Telephone
Dana 1 n{'l An/n,
Sprinkler System Information
Sprinkler Contractor's Company Name Telephone
Contact Person
Address License#
Signature of Officer(s)of Corporation
Fire Alarm System Information
Fire Alarm Contractor's Company Name Telephone
Contact Person
Address License#
Signature of Officer(s)of Corporation
Driveway Access
NC Deparknent of Transportation Driveway Access/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 any changes occur
including listed contractors, site plan, 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 •Ivl on of any and all changes.
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Signature of Owner/Contractor/Officer(s)of Corporation Date
Dane o..r o 4...n.
1
Affidavit for Worker's Compensation
N.C.G.S. 87-14
The undersigned applicant for Building Permit# being the:
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/have three(3)or more employees and has/have obtained workers'
compensation insurance to cover them.
Has/have one (1)or more subcontractors(s)and has/have obtained workers'
compensation insurance to cover them.
Has/have one(1)or more subcontractors(s)who has/have their own policy of
workers'compensation insurance covering themselves.
Has/have not 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.
Firm Name: 44L, IC.Pc JJ ers �c
By/fitle:
Date: CP f to l k `tj