BUILDING • Each section below to be filled out Application #
li . 5GC2 5
by whomever performing wort. 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.harnett.org /permits
name & phone must match
Application for Residential Building and Trades Permit
•
Owner's Name: Arvdrr t 1'I \Ace: \ �� Si-{ il Date: 28 Feh Xi I
' Site Address: I(Dyq() NC 2'7 0 f1TIl'Cl Phone: 919 VY
Directions to job site from Lillington:
LOX Nf . 21 6 inwards 27 . fine t nt,. Prass - One kan eris
r• /` a.611 •o oak eb. 1 Aq it . lg - S €Q iJ i
Subdivision: 1 Lot:
8 Description of Proposed Work: !Z$ QN nc \ai\khR 3wACcc rnk # of Bedrooms:
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: Slab:
,- General Contractor Information
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> Building Contractor's Company Name Telephone
A II
S AddZJ OW, Email Address
(5 Sig ature of Owne Contractor /Officer(s) of Corporation License #
Electrical Contractor Information
Description of Work Service Size: Amps T -Pole: _Yes No
44 avo Fr
Electrical Contractor's Company Name Telephone
/
; dd b -s. / Email Address
Si.' . ture of Owner/ o tractor / Officer(s) of Corporation License #
Mechanical /HVAC Contractor Information
Description of Work
44 Otrirrr
Mechanical Contractor's Compan Name Telephone
i
Ad. iyi Email Address
• ign. ure of Owner ontractor /Officer(s) of Ay .•oration 'cense #
Plu .,• • ontractorinforma'•n
Description Wor # :aths
Plumbing ontract• is Company N .me T lephone a 1
•ddres- E l- •.. ess
' ig : ture of Owner /Cone ctor /Officer(s) of C•rporati • License #
nsu = on C • t *ractor Information
As o4 ,'ct � ° �li
Insulation Contractor's Company Name & Ad.. ss Telephone
*NOTE: General Contractor must fill out and sign the second page of this application.
Residential Eat lding Appftafion '1 o 2 MM
,t W
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
\ i
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`, i
construction work to be done? / No
5. Do you intend to personally occupy the building for at least 12 consecutive • 1
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 any 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 rz H fee s li sdule. n 2 rM 91)//
p.ft) .�
ign ure of Owner /Con ractor /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.
iZ
Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance
covering themselves. CT
IX 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 Na e:
Sign w/Title: 2Olj Date:
Residential Building Application 2 of 2 10 /10