BUILDING • Each section below to be filled out Application #
by whomever performing work. Harnett County Central Permitting
Must be owner or licensed PO Box 65 Lillington, NC 27546
contractor. Address, company 910-893 -7525 Fax 910-893 -2793 www.hamett.orgipemiits
name & phone must match
Application for Residential Building and Trades Permit
Owner's Name: Jason Ragan Date: 2/14/2011
Site Address: 29 Wood Duck Tr., Sanford, NC 27332 Phone: 919 - 499 - 5487
Directions to job site from Lillington: Hwy. 27 W. T/L on Buffalo Lake Rd. T/L into Carolina Lakes Sub. Past guard
house and T/L on Cedilla Way. Go 1.5 miles and T/R on Quail Hollow Ext. T/R on Quail Hollow. T/L on Wood Duch Tr.
29 is at end of street.
Subdivision: Carolina Lakes Lot: 54 -1
Description of Proposed Work: Addition to Nook # of Bedrooms:
Heated SF: 40 Unheated SF: Finished Bonus Room? Crawl Space: _ Slab:
General Contractor Information
Marshall Johnson Construction, Inc 919 -427 -7111
Building Contractor's Company Name Telephone
283 Banner Elk Rd., Benson,y 7504 mljconstruction@msn.com
A• • Email Address
55274
Signature of a • /Contractor /Officer(s) of Corporation License #
Electrical Contractor Information
Description of Work add 2 outlets Service Size: 200 Amps T -Pole: Yes No
R. A. Jackson Electric 919 - 894 - 5367
Electrical Contractor's Company Name Telephone
9261 Raleigh Rd., Benson, NC 27504 rajacksonelectric@embargmail.com
Address Email Address
i/ ��,� � 21144
S /b natur r er /Contractor /Officer(s) of Corporation License #
MechanlcaUHVAC Contractor Information
Description of Work
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature of Owner /Contractor /Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
Signature of Owner /Contractor /Officer(s) of Corporation License #
Insulation Contractor Information
TriCity Insulation, 418 Person St. Fay, NC 28301 910-486-8855
Insulation Contractor's Company Name & Address Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Res denOnl Ftuddni9 Application 1 of 2 01210
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? _ 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
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 Mo r hs to 2 years permit re -issue fee is $150.00. After 2 years re -issue fee
is as er curce t fee s dul-
pp
2 -14 -11
Signature of Or r /Contractor /Officer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
1 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.
1 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: Marshall Johnson on • ion, Inc.
Sign wTtll // �, /— A/LGSL Date: 2/14 /2011
Residential Budding ■pplie;,tion 2 of 2 06:10