TRADE 4 / section below to be need out U by 2
'' +lever performing work Must be owner //
° � t �ca n s ed contractor Addre comp Application # 5 �O (p 4 J
4 name & phone meal match krorma8on on Harnett County Central Permitting
fJ ( ocense PO 9ox 66 ullhkglon NC 27548
} 910-893-7525 Fax 9104912793 www Monett orgnsennba
Application for Residential Building and Trades PermI
Owner's Name CvarSTOpwpv 0,4[4y Diet TOP Attu - er tali Q.,/ Date
Site Address L o t ?_ ., /l, 0 w ES Phone q /O 2 7 ? cii /n
Directions to Job site from LIIIIngton 21 s C y A r Th ,€ ,ed
/ -el+ ,9 Cr eetrvy lL rl yr/
GOB n r / Ey .1-
Subdivision 1 by I t 0 e k s Lot
Description of Proposed Work *Bedrooms
Heated SF Unheated SF Finished Rec Room? Crawl Space () Slab ( )
General Contractor Information
a -, : 1 _t 9/0 7 - c •
Building o •r's Company Name Telephone
0
WAt-r
Address License*
warns, uet elfin & MI out second page
Sign of Owner/ • • or/Officer(s) of Corporation
glectrlca l Permit Information
•ion of Work Service Size Amps TPole year o
0rk-11 /»- r elr,c 9/0 71/
Electrical Contractor's Company Name Telephone
)2 lit? 510 ,, 4 1 0 s t I 2s- Sl 2 sL
Address License Si
Signature of Officer(s) of Corporation
MechanIcahIHVAC Permit Information
• eecrlptlon of Work T ) lr ,L.y ,V 2 '/ N V 4 C
lIPS4._ NT. A c I/O- 2 o
Mechanics • _ • ea Company Name N Telephone
"7 ) G-r/t A Rd rK Wr 4tIll't Pc-if/or ° !92 (7
Address / License
Signature of Officer(a) of Corporation
Pio I P it Information
Description of Work a " n p /r. sal ay • I f l lflint it r.tc5,#
/1,/to !, rt.r.,s
Plumbing Contractor's Company N: e Telephone
• ^ O • -t mac .. c • a / . 2 U 0 V
Address License #
Signature of OM • s) of Corporation
Insulation Permit Information
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Ins on Contractor's Company Name & Address Telephone
PO QoX 93 ray1t/ev // ?kIca
821 08
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Homeowners Applying to Build Their Own Home
Please answer the following questions Then see a Permit Technidan to determine 11 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 supenntend and
manage construction of the project? _ Yes _ No
3 Do you intend to directly control & supervise construction activities _ Yes _ No
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 budding 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 taw 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 au 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
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
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
f/ 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 dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name Tc✓ /lcfi A < '/4 1 id , c, yih 4 s <<c
„ ign winds
_ — — Date — Z s it
Residential Builc ng Application 2 of 2 Mit