BUILDING 699 4c /f
Application # - / 5 27j
• Each auction below to be tilled out Harnett County Central Permitting
by b performing PD Box 65 Winston, NC 27546
contractor. Must ae 910 -893 -7525 Fax 910883 -2793 www.hemetorglpermits
owner or Nce nsed in®wor
namm owfr e g phonne e must a,tymhany match
®nears xoa for ftasidsntl Bltdldina and Trades permit
Owner's Name: Bledwell Homes Inc. f Date
Site Address: Q S OrCIlz2re F,' //r 2J,. 4dco)A Cite.! Phone: 919
Directions to lob sib from UOlrtgtpn: 27 N to Nursery Road. Left on Mummy. Anderson Creak Entrance is 3 miles
on lea. . 4 y 691 /`f /Gn yds 67f An rly k >. .
S00(114100: Anderson Creek O Lot:
Description of Proposed Work: New Construction # of Bedrooms: 8 L�
Heated SFp27VR Unheated SF: 173R Finished Bonus Room? / Crawl Space: ✓ Slab:
General Cordractor IMoml tOn
Blackwell Homes Inc 919-359-0079
Building Contractor's Company Name Telephone
PO Box 189 Clayton NC 27528
Addre Email Address
_/iy�. /�,�' — "- 52630
Signature of Owner!ContractortOfficerts) of Corporation License #
electrical Contractor Information
Description of Work New Construction Service Size: Amps T -Pole: l Yes No
Pioneer Electric 919-499 -7767
Electrical Contractor's Company Name Telephone
80 Neill Thomas Rd. Lillington NC 27546
Address Email Address
i/ : a 21843 -0
Signature of Owner(ContractorlOflicer(s) of Corporation License #
mechanical /HVAC Contractor Information
Description of Work New Consttuction
Carolina Comfort 919 - 934 - 1060
Mechanical Contractor's Company Name Telephone
Hwy 70 Business West Clayton, NC 27527
Addre$$ Email Address
A . l � � 20077
Signature 01 OWier!ContractorlOfficer(s) of Corporation License #
Plumbina Contractor Irdormetton_
Description of Work New CorreWction # Baths 3.5
Jamie Johnson Plumbing 910 - 2793742
Plumbing Contractor's Company Name Telephone
1490 Clark Rd. Llllington NC 27546
Email Address
21649
Sig re re of ner/Contractor/Officer(s) of Corporation License #
Tri-city insulation 910-488-8855
Insulation Contractor's Company Name & Address Telephone
'NOTE: General Contractor must fill out and sign the second page of thls applicatlon.
607 1 A6-
Homeowners Applying to Sulld Their Own Home
Please answer the (allowing questions than see a Permit Technician to determine If you qualify for permit wider Owners Exemption.
VIP Questionnaire per G.S. 87 -14 Regulations as to Issue of Budding 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 @py 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 anerer -�surent fee schedule. /
Signature of Owner/Contractor/Officer(s) of Corporation D r28(/‘0/
e
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), flrm(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.
d 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 workers compensation insurance prior
to issuance of the permit and at any time during the permitted work from any person, fire or corporation
carrying out the work.
Company or Na Bla awell Homes Inc
tbatro
sgnwmne: 41 rd ASsigc D Elb9Adl -