BUILDING ' Each section below to be filled out by Application it 0 57 ZS la/
whomever performing work. Must be owner Harnett County Central Permitting
or licensed contractor. Address, company PO Box 65 Lillington, NC 27546
name & phone must match information on 910- 893 -7525 Fax 910- 893 -2793 www.harnett.orglpermils
license. GOMMERC1tW..
Application for Building and Trades Permit
Owner's Name: 1, : /rn Csa /'l/ /pc/fir- Date: , . /i ?O/
Site Address: 5 4 a /7 4 <Eu . r'c,11 1 (Phone: J - .. —
Directions to job site from Lillington: e - i /. -/ di ' or. 1 ,
• ,.•1 s• '' / r` . i ) 7 / er—
pr/,' re// /= ii „4:).rr e
17 r
Subdivision: / to,. i r 5 S 7..,,.., Lot: .r
Description of Proposed Work: . . •!
Heated SF / ro/% Unheated SF ....,
General Contractor Information Building Cost $ 7'i
7/ -4 - ,C74.51
:uilding Contrac or's Company Name Telephone
r >, -: �,. r � 0
r .0, Y7r �r �7�' `, L•r� �^ / �C 7_41 � License
Addrsr7 / .
Must sign & fill out second page
Signature of O,wt er /Contractor fficer(s) of Corporation _-
Electrical Permit Information Elec Cost $ /a /.200
Description of Work C onwix *r / Cirri( ; Service Size: Amps #TPoles____
- 7 . ,, . " . . 9/b - C 9 -003"9 •
Electrical Contractor's Company Name Telephone
/.7 7Jnnlarl LAW' 15 K v in be- // cense# -L/
Andress
•,.a r
�S - - :ture of 0 er(s) of Corporation s
Mechanical Permit Information Mech Cost $ t
Description of Work , 7Y 4 ('"„Oft C2 4 1/ 4ler # Units /
Mechanical Contractor's Company elep one •
Na ? Cater ' • r . 1 f /778 75
Addre - - License #
re o er(s) ' of Corporation p
Sig atu oration
Plumbing Permit Information Plumb Cost $ 1), /2 9 —
` Description of Work 6 r 7AJr /sr. # Baths ,/ "?''' •9 1t';,F „17 c r//f, _., TF ~6 :T /Z'.
Plumbing Contra ors Company Name Telephone
- 2:1 1. 2 . A/n/ Pee ✓ai t .s7lrrwiia? •77C6--
. C - P/
Addres License #
Signature (s) Corporation
Insulation Permit Information
sulation Contractor's Company Name .& Address Telephone
801 /08
Sprinkler System Information
Sprinkler Contractor's Company Name Contact & Telephone
Address License #
Signature of Officer(s) of Corporation
/', ,dire Alarm System Information
I� nr c) .* e - rn/re?/ /lfY a 7/tP- $y4- r'7C '✓ I r
Fire Alarm Contractor's Company Name Contact & Telephone
c i'7f --
A°�dr ss License #
Signature of Officer(s) of Corporation N
Driveway Access - NC Department of Transportation Driveway Acc j�
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 am 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 as per current fee schedule.
- Signature of OwierfCor1ff for / Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned 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.
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 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. / J
Company or Name: f /� /c,:::.t9 C� /y jiai r
Sign wrritle j j�;: c �?`'lz_c_ Date f /,, al/
•
8121/08