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BUILDING 0 —I Application # // C" 3/ P 2 6 ✓ i` 5 Each section below must be filled out by Harnett County Central Permitting is performing the work Must be y g owner or licensed contractor Address PO Box 65 Lithngton NC 27546 company name 8 phone must match 910 893 7525 Fax 910 893 2793 www harnett orgfperm is information on state license COMMERCIAL /� J Ap !wallop / for Building and Trades Permit / Owner s Name C _�(�/v ^) /� /'r 0 7e, /7 Date j / /nit"' 4 SiteAddrfg 1 C CA Phone cj1 / r *s?' Direct ons to lob site from Lillington 4 7 y in Cop ` : 94 I' o'5 ii 454.t m€� �/ , o - 6 ,.- R 1 S i - cy S} jsZ 6 a 7 87t I Subdivision Lot e Description of Proposed Work iJ $ ? Heated SF Unheated SF 1 � ene ral Co actor Information Building Costtr[� co © Cam, 5p) - S ?/ dYg? Z Building Contractor s Company Na Telephone 2 9 5 /get /, , (,e /5 N C Add s: / / / // Email Address / S 'e of Owner/ ontractor /Officer(s) of Corporation Lice f se c c * Electrical Contractor Information Electrical Cost $ J 'C ©d D - scrlption of Work Service Size Amps #T Poles I:. — r i s is .4 firs 9) b '-93 5'775 Electrical Contractors Company Name 1l Telephone 15 o 9 Af n rf1. ✓�l P,a -t 6 L 11 - td 0 k Ad ress g� n Email Address n•n, 4 LAIi t aeia40b L"Q it Signature4o Owner /Contractor /Officer(s)�of Corporation License # Mechanical Contractor Information Mechanical Cost $ 02 tw - ..... Description of Work /VA/ //w✓ # Units _7 ' 77i4H / /1PeO /we / /11/ x v'c. 9/9 10 / 26 Mechanical Ctintractor s Compa a Tele hone i /Qi A3 196 b , n 1 // ./V-C Z7 5 Zl ,P-✓•Owy 0P�'1tidae�,�t / i voA-, Address Email Address '4,. ., 2 7 %1 &55 . T 7 Signature of Owner /Con ractor /Off'icer(s) f Corporation Lice e # * Plumbing Contractor Information Plumbing Cost $ l l 6OO Description of Work # Baths ` �C/� /v.-7,-,- C‘-' Urn a PII./ d C 9 /q — g75 kmbing Contractor s Company Name . Telephone 1.901 ,ax '3 7 --,..r NC a75.0174e, k s0 to G'A d, /0 orh Address c / � 1 � E l l a i�S s Signs u of Owner /Contractor / Officer(s) of Corporation License # Insulation Contractor Information Insulation Contractor s Company Name & Address Telephone NOTE General Contractor must fill out and sign the second page of this application Comm I B Id ng Appl catio 1 of 2 08/10 7i Sprinkler Contractor Information Spnnkler Contractor s Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Fire Alarm Contractor Information Fire Alarm Contractor s Company Name Telephone Address Email Address Signature of Officer(s) of Corporation License # Driveway Access NC Department of Transportation Driveway Access/Permn Yes No hereby certify that I have the authonty 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 tux changes occur including listed contractors site plan number of bedrooms building and trade plans Environmental Health permit changes or proposed use changes 1 certify it is my responsibility to notify the Harnett County Central Permitting Department of any and all Expi d Permit Fees 6 months to 2 ye permit re issue fee is $150 00 After 2 years re issue fee is c arged at f price per urrent fees dule fit .14 0 2-7 Pun- 77 Signature of Owner /Contractor /Officer(s) of Corporation Date Affidavit for Worker s Compensation N C G S 87 14 The undersigned applicant being the X General Contractor L 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 co ring 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 t � / //'2 y/ Company or Na : »4 4e1 � ` q � Slur 1 `J� 5/ �t / 1 (ar / Sign wfritle r � Date v"� /" �/ C mm rc al 8 Id g Appl t 2 of 2 08/10