BUILDING Each section below to be filled out Application # " / C 2 ‘ /7
by wfiomeverpeAomdng work. Harnett County Central Permitting
Must be owner or licensed PO Box 65 Lidington, NC 27548
contractor. Address, company 910- 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
name & phone must match
•
Application for Residential Buildlna and Trades Permit
Owner's Name: t�r�` �L4 - -e4.— i Date: 3 - y - / /
Site Address: /� 74 / t:C7 a�, ony /�-U' Phone: Y*2 / 7. (i
Directions to job site from Lillington:
Subdivision: Lot:
Description of Proposed Work: # of Bedrooms:
Heated SF: Unheated SF: Finished Bonus Room? Crawl Space: _ Slab:
/f General Contractor Information
4 fib*?
b*?
Building Contractor's Company Name Telephone
Address , rte— Email Address
Signature of O r/Contractor /Officer(s) of Corporation License #
Electrical Contractor Information
-scription of Work Service Size: Amps T -Pole: es No
Electric- Contractor's Company Name Telephone
Address Emai ddress
Signature of Owner /Co ractor /Officer(s) of Corporation License #
Mechanical /HVAC Contractor I r • rmation
Description of Work
Mechanical Contractor's Company N. • e Telephone
Address Email Address
Signature of Owner /Contractor /Officer : of Corpo - on License #
- lumbina Cont : ctor Information
Description of Work # Baths
Plumbing Contractor's •mpany Name Telephone
Address -.ail Address
Signatur: of Owner /Contractor /Officer(s) of Corporation License •
Insulation Contractor Information
/Insulation Contractor's Company Name & Address Telephone \
C// 'NOTE: General Contractor must fill out and sign the second page of this application.
Residential Building Application 1 of 2 08/10
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Pemnit 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 cdmpletion 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 as y 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 pe current fee schedule.
3-z/
Signature f Owner /Contractor /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(e) 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.
Company or Name'
Sign w/Title: 11? -iii Date: 3-4-77
Residential Building Application 2 of 2 08/10