BUILDING Application # 1 f Z /24
• Each section below to be tined out Harnett County Central Permit whomever performing vedrk Must ting
owner o licensed PO Box 65 L P ltxpon, C 2754
r
contractor. Address company 910-893 -7525 Fax 910893 -2793 www.hamettorglpennita
name 8 phone must match
Aodicatlon for Resldentlai Buildfna and Trades Permtt
Owner'sName:7 &t Char key ic C /.w• t7 a74ls LLC Date: -J
Site Address: Phone:
Directions to job site from Lillington: ;,2/ 5. ro Over ' I f s Rd Pt re. fa N. es /ow
/e rrfi to S t o p Si o ti. Pk'-t Car'te'r
Subdivision: t''Ote,,-I-'r Sr(. ° a/ e5-rates Lot: miff
Description of Proposed Work: /11 i{a r.4 S e # of Bedrooms: 2
Heated SF:(5/ f's Unheated SF: 4 1,)4° Finished Bonus Room? Crawl Space: _ Slab: t/,
General CoaiSitor loformatfon
(' %.+ a n.cr V i e Crif. — /-i tic o z fez - 32 - y95 - f
Building Contractor's Company Name Telephone
g .1 &nr3- LA"' SPA ,....s Li. -K( NC re C. c, /X.<.. Co"
Address Email Address
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�f, as C 66 e3.5
Signature of rJContractor/Offl r(s) of Corporation License #
Electrical Contractor Irtfonnatfon
Description of Work 4. /.': L Hoar et Service Size: 20 a Amps T -Pole: 0 No
Peoltc aLC /tve. 9/9- 9sy • n
Electrical Contractor's Company Name Telephone
P.O. f5o". 1 / 36 All Lei s!. N. 0: ;17611
Address Email Address
I /
re of Owner • ntractor • cer(s) of Corporation License
MechanicaUHVAC Contractor Information
Description of Work //✓ s :l id- Cony! L. PI ft s -.rc s y 1 fl'
Ceetnpa oft-o -r...5 ,F €....L. ... 3-'co- oaoo
Mechanical Contractor's Company Name Telephone
a.�,. tbvy 1024 140 k into Ate- 3-1344 W /y
Address Email Address
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Sig ture of OWn clot /Officer(s) o fCor poration License #
Plumbing Contractor information
Description of Work P L u n wk. Li j fr. -3E # Baths
R 't n^-b 655 1 / 4 - 1 C- g69-, - r2- 49fl
Plumbing Contractor's Company Name Telephone
P w t4 .1 NC _ a ?r31 4
MJ Email Address
S�ture of Owner/ mss) of Corporation License # r
Insulation Contractor Information Q
(tv5•- 1 -at1.✓ inle 1i — 7 7 6 — L1 /38
Insulation Contractor's Company Name & Address Telephone
Fine g the _ C&-n/ Yi dea)
*NOTE: General Contractor must fill out and sign the second page of this application.
SFD, Addition, Modular Application 7 of 8 08110
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technidan 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
1 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 Hamett County Zoning Ordinance. 1 state the information on the above
contractors is correct as known to me and if anv 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. After 2 years re -issue fee
is as per current fee schedule.
( 7 d — 2 cs/ 0
Signature of Owner /Con re or /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant being the:
/
V" 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.
L/ 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.
Company or Name: � o t i n b a r ., e f, icy C. r -to'. J /ait e s L L Q.
Sign w/Title: Zip+ t �r�s •• Date: (1 `.2 "( 0
Residential bustling Application 2 of 2 03/10