BUILDING Application #
Each section t>plow to be filled out
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 harnett org /pemiits
name & phone must match
pp Application for Residential Building and Trades Permit
Owners Name Ck+ss /tl,/ean/ Date 3
Site Address 1� L itiAroseM LN Phone Uai1 210g
r ' D rections to job site fro Lillington
Subdivision Els a 1344.0nwt Lot "7
Description of Proposed Work G.' 0Z4 # of Bedrooms
Heated SF Unheated SF _Mt, Finished Bonus Room Crawl Space Slab
General Contractor Information
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Building Contractor s Company Name Telephone
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Addres Email Address
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Signature of Owner /Contractor / Officer(s) of Corporation License #
Electrical Contractor Information 7�
Description of Work Service Size t A � m r p � s T Pole No
/I Elec-jr al ' L'/C��' !l) J D'
Electrical Contractor s Company Name Telephone
9o wntOOP... Rd 3X/4F pc
Address
09-11542D- Email Address
Signature of caner /Contractor) of Corporation License #
Mechanical /HVAC 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
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Plybung Contractor s Co(npany Name Telephone
i1 i S Nca- -008 `t
Ad. /I Email Address
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Signature of Owner Contractor /Officer(s) of Corporation License #
Insulation Contractor Information
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Insulation Contractor's Company Name & Address Telephone
NOTE General Contractor must fill out and sign the second page of this application
tt 81 l2 6 Id App Cat° 1 of is
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 - ption
Q''- - onnaire per G S 87 14 Regulations as to Issue of Building Permits (Memo available u.. request)
1 Do you ow • - land on which this building will be constructed? Yes _ No
2 Have you hired or inte • • hire an individual to superintend a
manage construction of the prof- • ? _ Yes _ No
3 Do you intend to directly control & supe o.= ruction activities? _ Yes _ No
4 Do you intend to schedule contract • cirectly pay for - oases of
construction work to be done? Yes No
5 Do you intend to • - • nally occupy the building for at least 12 consecutive
months follow' • ompletion of construction and do you understand that if
you d. • : •o 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 per current fee schedule
n % 3-71-11
V "Signature of Owner /Contractor /Officer(s) of Corporation Date
Affidavit for Workers 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 /
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 nn I}
Company or Name S 4 4 Resto u � (Jr if‘
w/Title £f /� c ( c r Date 1) 4— /
Pes rental 6 la' la u A p ca o of 03/1