BUILDING Each section below to be aped out Application # /P5 2 / �/ g
by whomever perfuming work. Harnett County Central Permitting
Must be owner or licensed PO Box BS Lillington, NC 27548
contractor. Address, company 910-893-7525 Fax 910 -893 -2793 www.hamett.org/pemdts
name 8 phone must match
Application for Residential Building and Trades Permit
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Owner's Name: Awn Li..4 Date: 4A /0
Site Address: ;7)/ (\OM Co.r +— &cod o Jt Ai t , Phone: 9/9-C39-9207 Z
Directions to job site from Lillington: y en /e � /1,11 iQ 7 145 /fin ityAt
Subdivision: 7- e.01 Pr Lot: /00
Description of PropSsed Work: /j'tN li+z•. # of Bedrooms: 3
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: lab: _ 61 I. ��
/� `r 74,74,-. el./9- Contractor Information
J.re /.ers. sa 1(—/q
Building Company Name L Telephone Or
Addrgss , / Email Address
(/6.2 91
Signature of Owner /Contractor /Officer(s) of Corporation License #
/ Electrical Contractor Information /
Description of Work Nr,W ltnrhp. Service Size: _ Amps T -Pole: //Vas No
RA.. .ScAsn,. £&% ,. 9/4. /,>?s7
Electrical Contract° 's Comps Name Telephone
90 /4/ ' i i / moss, ti,C. 87509
X q�
Email it
Si ne re •� er /Contractor /Officer(s) of Corporation License #
Mechanical/HVAC Contractor Information
Description of Work ,'%4' /4"e.
51914see. f�r� a ,4'r2 9,4- 3,25- °6F
Mechanical Contracto4Com any Name Telephone
393 5494.1/ fig C a/wit/`.�. 127545
Address Email Address
ic
S gn of Own /Contractor/Officer(s) of Corporation License ense # #
Plumbing Contractor Information
� tl� of Work �4� # Ba
Plumbing Contractor's Comp m e Telephone
3/G0 d ;nom, .c, "2s1
Addre i it / Email Address
.? .4 /$
i • natur i7 Owner/Contractor/Officer(s) of Corporation License #
/ / Insulation Contractor Information Tom rCS*/ nv� ,s/5 0 /�a ,ir��f.�x/r e&nver gig - 16./ o/99
Insulation Contractor's Company Name & Aess Telephone
`NOTE: General Contractor must fill out and sign the second page of this application.
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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? _ No
2. Have you hired or intend to hire an individual to superinten. "
manage construction of the project? _ Yes _ No
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3. Do you intend to directly control & superv' -'= construction activities? _ Yes _ No
4. Do you intend to schedule, con , or directly pay for all phases of
construction work to be done? .. _ Yes,. _ No
5. Do you intend to p = -onally occupy the building for at least 12 consecutive .
months following pietion of construction and do you understand that if
you do not do - it creates the presumption under law that you fraudulently
secured the , . rmit? Yes No
I he :by certify that I have the authority to make necessary application, that the application :11 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 air y 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. After2 years re -issue fee
is as per current f: a s • edule.
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Signature of • er /Contractor/Offlcer(s) of Corporation Dat
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The unders' ed applicant being the:
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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.
_ Has one (1) or more subcontractors(s) and has obtained workers' compensation insurance to cover
them.
iHas 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 of the permit and at any time during the permitted work from any person, firm or corporation
carrying out the work.
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Company or Name: n 'ASA 4 c-✓'O ^
. Date: 6/6 Sign wlTitle: Air ,
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