COMM BUILDING 'Each section below must be filled out by Application # /L Fa, 2J y75
Harnett County Central Permitting
whoever is performing the work. Must be
owner or licensed contractor. Address, PO Box 65 Lillington, NC 27546
company name & phone must match 910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
information on state license. COMMERCIAL
Application for Building and Trades Permit
Owner's Name: A #JADE! A FEpp4 j.1 #+zrG Date: 1- / 0 -II
Site Address: to 7 79 OvEr ws 146 121 . . l.l #Trt 11)4 Phone: 9;o 4.7o - Z37
•
Directions to job site from Lillington: 7jkc .2 !n ' ,. 1 a-I `Pr'it / ,a4; C-
• (/ . - &A '. _.. b . , - 1 - / o - . . Pr/ t' ✓t For-4 ! , i tan
E,)-kripi,z lP4,4cy (kr.. ,SS i-1r,0rn Over* tic _.ltnn,S
Sueeioisicn:_. P Lot: A/ A-
Description of Proposed Work: -_ . , _' ,e, 'n 1 i a • ,_, • ox
Heated SF (2,005( Unheated SF
General Contractor Information: Building Cost $ 2(p, 925
r n A4Dnatn0 Ca1sTr<w.tc7rnn -! zn►c . ctin - N Z 3 - 51 2 2 or LIZ5-a3( $
Building Contractor's Company Name Telephone
nit, sr,nneepd , hate rn; Ils,/JL ZS sqk rn 99� nc. rr. corA_
Ad ess Email Address
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Si nature o Owne Contractor/ er(s) of Corporation License # -
o ,
Electrical Contractor Information: Electrical Cost $ 2, (o Z5
Description of Work Tetk,II 14 /Ret 1.4 /4 Service Size: Amps #T- Poles
C'. 4.tA) 1"Jrcrtetr , C-30- 199
Electrical Contractor's Company Name �// .
Telephone
T :39/, e ll e ht �71c /L/E ;/V' C
Address / Email Address
Sigtiafure of Own r C b ac r)Oflicer(s) of Corporation License # oc
Mechanical Contractor Information: Mechanical Cost $ C160
Description of Work is7/it? 4 6'!r±[/iie / # Units
.DWN)iLt_ If auf,e4, J SIA,,r r CO. n
Mechanical Contractor's Company Name / /r Telephone
�S/ 7 rnainey 2Gl, 4 4 /K gL.r C�l�l/%SOYI.S�/J/l(" {f�X! //l
Add � d : /% — Ell t ss J
Si azure of Owner /Contractor /Officer(s) of Corporation License �#� e >:
Plumbing Contractor Information: Plumbing Cost $ S' I / "' C
Description of Work I }o -OA n& a 1 ;nKs 40 ;a4;.,r 04444 sari& II ^e Baths IV th G -K 1 s i t #JG-
Rfhl G %a/2 /dGc /) c -, t /c %76'. OW
Plumbing Contractor's Company Name Telephone
eS
Addr ss / Email Address
�2 /��-I4.4 ), 6
Signature of Owner/Contractor /Officer(s) of Corporation License #
Ins Cont actor Information
• Insulation Contractor's Company Nam i ss Telephone
*NOTE: General Contractor must fill out and sign the second page of this application
Clon imercial Building Application • 1 of 2 :Th 0
Sprinkler Contractor Information
Sprinkler Contractor's Company Name Telephone
I (:\ Address Email Address
Signature of Officer(s) of Corporation License #
Fire Alafm Cont ctor Information
Fire Alarm Contractor's Company Name Telephone
Address �J Email Address
Signature of Officer(s) of Corporation License #
Driveway Access - NC Department of Transportation Driveway Access /Permit? Yes
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 a!{ 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 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
is arged at full price per current fee schedule.
• i natur of wner /Contractor /Of icer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The u ersigned applicant being the:
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.
as 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
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. �t -
Company or N Vie:: 1 y�� v AL:DOn /APO l�'''n ttA cT ,on) In 1l.
Sign w /Title: wL - ti 9 2 �i bsr ekir Date: 1— i Q —1(
Cornmenciai Building A: plicaikn 2 of 2 3110