BUILDING 09/09/11 Application#
Harnett County Central Permitting L/e 9u2
PO Box 68 tangles NC 27818
Each rection Below to S Ned out 910 8931828 Fax 910 893 2793 www hese orylpsmib
by whomever pert a1w wok
Must be owner a toned
contrasts Address company Aoclwalwn for Residential Bwldlnn and Trade.Pane'
nine 6 phone maimed, / / 9
Owners Name / ri t / MC ft05 //C Date / c7
Site Address : S _ . R'C S. t,r t t G /Phone ?/19-..? 6/_/ e
D, ionto job site from Ldhngton yo N 71J C rill sic, r) 1 f L a (WKe:O+,/
Kot - L- TO rIo fres @nLir/ PA.rk 2-4/2-4/ - L to snit.
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subdwiswn Co K`J " PI /'ti r A / Lot 2//%
Descrpbon of Proposed Wads (1 r n r [, pr�rnJ C #of Bedrooms '6-
Heated SF Unheated SF Jr J Finished Bonus Room' Crawl Space _Slab X
c. AIA,c-r Pros L 9/9-2fG/ng
Building Contractor s Company Norse Telephone
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�3/ 2 /a.. P, cti Lam✓ rc,7)m / 1,5r:Ac NG T/T//1e c3 (.Cirri
Address / / Ernes!Address
License�
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Descnptan of Work /l/LW Ar, e e et .we rSrice� S ffi
vAmps T-Pole Yes No
Oct wso., s �/&Ari in C -o,2 sic
Electrical Contraclof s Compaq Name Telephone
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s< o /? e--0henei Qrl, Ff c/Var;.,gr i1/'G Traces@- D colicas 5£elr,C. Qvi✓1
Address / / Emad Address
5-75 - t
License#
ilininGlafreaDIDISABrirldiSta
Desatption of Work /VA
Mechanical Contractors Company Name Telephone
Address Email Address
License# ohunlara Contaget IMormahon
Description of WOrk /I /A #Baths
Plumbing Contractors Company Name Telephone
Address Email Address
License#
insulation Contractor Information
Insulation Connector s Company Name&Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
I hereby certify that I have the autonty to make necessary application that the application is correct
and that-the construction will conform to the regulations in the Building Electncal Plumbng and
Mechanical codes and the Harnett County Zonwg Ordnance I state the mfonnston on the above
contractors is correct as known to me and that by s:^mna below I haw obtalnad a0 suhcanbactots
psnnhsston to obtain these permits and if goy changes occur including listed contractors site plan
number of bedrooms budding and trade plans Environmental Health pent 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
o ice per :Wetn
is
of Corporation D
Affidavit for Workers Compensation N C G S 87-14
The undersigned applicant being the
X-- General Contractor _Owner OnicerlPgent 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
Has one(1)or more subcontractors(s)who has thew own policy of workers compensation insurance
covenng themselves
_Has no more than two(2)employees and no subcontractors
While waiting 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 waters compensation insurance pnor
to issuance of the permit and at any time dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name �✓ S c
Sign wrtNerLGA
/P�r S,' cn T Date 941/261/4?