BUILDING LI 5.030
Each section below to be filled out by Application#
whomever performing work. Must be owner
or licensed contractor. Address,company Harnett County Central Permitting
name 8 phone must match information on
license. PO Box 65 Lillington,NC 27546
Phone 910-893-7525 Fax 910-893-2793 www.harnett.org
Application for Residential Building and Trades Permit
Owner's Name: Le mai7lJIS5l UGIW�^r Date:711-72-/-
�n
Site Address: 7b 95 At seat Zig,. in- Phone: / '1 79-1 $z/2-
Directions to job site from Lillington:
Subdivision: '2 �L'L, 2 6 /Lot: 1
Description of7Proposed Work: 30 X1Y��fayna�/ yb&d#Bedrooms: 7 /
Heated SFJAe?O Unheated SF 15421 Finished Rec Room? Crawl Space y/Slab( )
/ General Contractor Information
ICC la.,kbw [cC 419— nt_ 6317
Building Contract is Company Name T ephone
Soy cc, / -;, A, , it ;2733L 4139651
Address License#
Must sign 8 fill out second page
Signature of Owner/Contractor/Officer(s)of Corporation
Electrical Permit Information
Description of Work Service Size: VO Amps TPole:yes()
CAacct. n Ru sac 9r0-9517 - 7707
Electrical Contractor's Company Name Telephone
)700 N'-y fr--.to/ Car Mac A/C 21327 723 Vo
Address
.� f License#
Signature of(Nficer(s)of Corporation
Mechanical Permit Information
Description of Work
(n+ut:.49 , Zic 9taIn'7707
Mechanical Contractor's Company Name Telephone
3+o0 /4.y /r-C-0/ Ar ti. aye Ate 11527 ZSil'9
Address ��++��//////�� License#
Signature of flicer(s)of
Plumbing Permit Information
Description
of XJork #Baths
PlunLi7nggContractor's
,(C,ompan N me ,/r �y�j Teledhone Y
Addr 31 (k ��/ 1110 a7370 /D?License#
i
Sig azure of Officer(s)of Corporation
Insulation Permit Information
Insulation Contractor's Company Name&Address Telephone
Page 1 of 2 9/07
Application ft
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 no
2. Have you hired or intend to hire an individual to superintend and manage construction of the
project? yes no
3. Do you intend to directly control & supervise construction activities? yes no
4. Do you intend to schedule, contract, or directly pay for all phases of construction work to be
done? yes _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 any 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 sponsibility to notify the Harnett County Central Permitting Department of
any and all changes.
L /jJi8
Signature of Owne ntractor/Officer(s) of Corporation Date
Affidavit for Worker's Compepsation N.C.G.S. 87-14
The undersigned applicant being the: Y//
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.
one (1)or more subcontractors(s) and has obtained workers' compensation insurance to cover
th
7Has 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 01 the permit and at any time during the permitted work from any person, firm or corporation
carrying out the work.
Company or Name: Iv/(// LI t v
Sign w/Title00:"‘....- firth
Date: 4/i hi
Page 2 of 2 9/07
Appointment of Lien Agent:Details-LiensNC Lien Service https://apps.liensnc.com/ser/appointment/details.html?entryNumber-85...
DO NOT REMOVE!
Details: Appointment of Lien Agent Filed on: 05/29/2018
Entry #: 859175 Initially filed by: Burtonbr
Designated Lien Agent Project Property Print & Post
Fidelity National Title Company,LLC PM-052801-9452000 PID-130528015703 ria W 17
NC Hwy 27
Online:anew liensnc corn- .mss Lilting-1m NC 27932 I!q
Address:19 W.Harden S.,Suite 507 I Racial,NC Hanan County O
2701
Contractors:
Phone:888-690-7184 Please post this notice on the Job Site.
P.,.9us89s21i Property Type
Suppliers and Subcontractors:
Em.w su000nCeemnc come..-..eoavvs, Scan this image with your smart phone to
view this fling You can then file a Notice
1-2 Family Dwelling to Lien Agent for this project
Owner Information
Date of First Furnishing
Leland&Melissa Johnson
1850 Kenwood Ave
Sprang Lake, NC 28390 0529/2018
United States
Email:none@none
nom
Phone 919-721-8242
View Comments(0)
Technical Support Hotline:(888)690-7384
I of 1 5/29/2018, 11:26 AM