BUILDING Harte Electric, LLC
1-800-957-1873 p.1
Mar. 1. 20 9:32,PM Amazing Spaces No. 8086 P. 2
Each section below to bo filled cur Application #
by whomever performing work. Harnett County Central Permitting
Must be owner orlcensed PO Box 65 Lnringron, NC 27590
contractor. Address, company 914993.7629 Fax 910- 693.2793 www.herre6.otwpennas
name & phone mint match
Application for Residential Building and Trades Permit
Owner's Name: St At YtaYYS Date:
Site Address: aoc& Gull it lino J 6w,Sfinchlrri mca" 135D Phone: (114 •'MR -/ rl i
Directions to job site from LIIAngton: CC) Bf1 Ltr1 in Sl — ' N . ( P1
4 Cla Rd -;G PRuccoon mks -'tom Crnaotina L&urts —;
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Subdivision: Crt f V tna Lit its Lot
Description of Proposed Work: SuntOCrn _nrtftl ti tjrl # of Bedrooms:
Heated SF:30% Unheated SF: Finished Bonus Room? Crawl Space: _ Slab: _
General Contractor Information
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Building Contractor's Company Name Telephone
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Addr S Email Address Suir►rta a,m , adi rl
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Signature of Owner/Contractor/Officer(s) of Corporation License #
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Description of Work _ _ 0 IL.M11 (: S Semite Size: Amps T -Pole: Yes No
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Electrical Contractor's Company Name Telephone
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•' dress /�� 91 Email Address
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nature of Owner /Contractor /Officer(s) of Corporation License if
MechanicaffHVAC Contractor Infommtion
Description of Work
Mechanical Contractor's Company Name Telephone
Address Email Address
Signature cif Owner/Contractor/Officer(s) of Corporation License it
Plumbing Contractor Information,
Description of Work # Baths
Plumbing Contractor's Company Name Telephone
Address Email Address
Signature of Owner /ContractorfOfficer(s) of Corporation License Of
Jnaulatlon Contractor Information,
f 0U(t SF 4,SUNS 227 r'CD[FN; 1 / 4 1 (oo
Insulation Contractors Company Name &Address Telephone
*NOTE: General Contractor must 011 out and sign the second page of this application.
Residentai Auikling Application 1 of2 O6/IC
Received Time Mar. 1. 2011 1:08PM No. 8091
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 ate( 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 per current fee schedule.
1S.K N - zo l l
Signature of Owner /Con racto fficer(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 - 14
The undersigned applicant being the:
X 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.
]( 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: f Ss9 n M G
t Sign w /Title: .k_ \ )\ a Pea looks ree.,1 t. ems— Date: t. ' Lo I
Residential Building Application 2 of 2 08 /1 0