BUILDING Bach s et o b 1 w to he ni dot Application # O7$ 2/62 9
1 y who 1 pod g w k Harnett County Central Permitting
P4 st be ow e 0 1 sed PO B 65 1 11 gt NC 2 546
t a 1 Add e t y )10 893 7 25 I 10 8J3 1793 WWI, 1 lett q/p is
a & ph r n 51 tch
Application for Residential Building and Trades Permit
Owner s Name Wy In Constn etion Inc Date 3" /7 '
Site Address Z f�Z iJi uv O de- Phone 9//9 10 0 3 7945
Directions to job site from Lillington _ H &Y 22 k/ 7 OZi #Hif jan ow& th
-Le-41 o,w' nilo o n dAt Bit 6 tr "
Subdivision nitro en P027 TG% Lot 4 /7 3 y
Description of Proposed Work New Consta cl 01 # of Bedrooms 3
Pr
Heated SF �7V Unheated SF SVZ Finished Bonus Room? 41 Crawl Space I Slab
General Contractor I nformation
Wyn Coistruct 01 Inc 919 603 796
Building Contractors Company Name Telephone
2 50 Cayitol Dr C eed loor NC 27522 edwnrd @wynnconst ct com
/{ / / '�' ' Email Address
/ re �/�./ � / 1atAi 46295
/ Signature of ner/ ontr ctor/ fficer(s) of Corporation License #
Electrical Contractor Information
1 Description of Work New Construction Service Size 200 Amps T Pole ✓ Yes No
R A Jackson 919 730 1251
Elect ical Contractor s Company Name Telephone
9261 Ralcgt Road Bens 11 NC 2/504
Address r , � i
-) ` p Email Address
C`3 ('f \\ _ __ _ 21144
Signature of Owner /C tractor /Officer(s) of Corporation License #
Mechanical /HVAC Contractor Information
Description of Work Nr w Construc no 1
Stephen o HVAC 919 329 0686
Mechanical Contractor s Company Name Telephone
343 Shrpwa h D Girner NC 27529
Address Email Address
1 18644
Signature of Owner/Contractor/Officer(s) of Corporation License #
Plumbing Contractor Information
Description of Work New Co struction # Baths
TI n ton s PIU 1b ng 919 669 8655
Plumbing Contractors Company Name Telephone
3160 A Omar Rd Clayton NC
Acc cress / / , 4i� -j�7^ T Email Address
Li!r'7 Af ftrt ,, 22152
Si naturi of Owner/Contractor/Officer(s) of Corporation License #
1// Insulation Contractor Information
Tat m I st lal on 913 661 0399
Insulation Contractor s Company Name & Address Telephone
NOTE General Contractor must fill out and sign the second page of this application
Homeowners Applying to Build Their Own Home
F Itas we It e follow i q cst to is then see a Perm I Tech t a to dote e I yo q al ty for pent under Ow e s E e not o
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 tnat 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
EXPIRE* PERMIT FEES 6 Months to 2 years permit re issue fee is $150 00 After 2 years re issue fee
is as p- current ee hedule
LALooLealf 3-1y-II
/Sig ture of Owner /Contractor /Officer(s) of Corporation Date
1 / 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) finn(s) or corporatron(s) performing the work
set forth in the permit
I 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 Na - W y 1 Co trucho 1 Ito
Sign w/Tdl
Sad" Date 3-it/-//