BUILDING Each section below to be filled out A,3
by whomever performing work Harnett County Central Permi Application # J) Ii ( Li
Must be owner or licensed PO Box 65 Lillmgton NC 2754
contractor Address company 910-893 7525 Fax 91 0 - 893 -2793 www hamett org /permits
name & phone must match
A Iication for Residential Buildin and Trades Permit
Owners Name a• •
t I - rS
Site Address • Date (y ii
Directions to job site from Ltlhngton • * i r n • v! Phone
9t4 a�Evi
• IS ., Lc l e
- : s
Subdivision r ;A L,. IA • /-
Description of Proposed Work & _ , , Lot
# of Bedrooms
Heated SF ' Unheated SF 22522_ Finished Bonus Room?
General Contractor Information Crawl Space Slab � � c(
:la Pus °.. a
Building Contractors Company Name ! G (o R4 2Tsr_
• et ,-S Telep one
Address L • • C r
J Email Address
Signature of 1 ner/ .ntracto lafficer(s) of Corporation $ 3 (O7
fi"/
Electrical Contractor Information
Description of Work g License
Size ,901) Amps T Pole !des No
Electrical Contractor's Company Name q q
(99 Q2/
I V( Telephone
Address v. }. r--------
Email Address
Signatu of ner /Contractor /Officer(s) of Corporation U�� _L
____ License cal/HVAC Contractor Information nse #
Description of Work Q 1 ,/
Mechanical Contractor s Company Name __ qq ( —ao c7
3 c � ' L { Telephone
Address '' J f
•../a Email Addr
Signature Owne on or /Officer(s) of Corporation t ` S S
Plum bin Contractor Information L icenss e #
Description of Work e L/
# Baths_
Plumbing Contractor s i Company Name
Telephone
Addre
- -. Email Ad dress
Signature of O ner /Contractor /Offcer(s) of Corporation I S RA______
Insulation Contractor Information
License #
7» co
Insulation Contractor s Company Name & Address
Telephone
NOTE General Contractor must fill out and sign the second page of this application
R de t al B Id g Appl cat o
1 oft
08/10
Homeowners Applying to Build Their Own Home
Please answer the following Techmaan to determine if you Questionnaire per G S questions 87 14 R gulatio s as Issue of Building Permits r(M available Owners Exemption
l able upon request) for permit under
1 Do you own the land on which this building will be constructed
2 Have you hired or intend to hire an individual to sup)zrmntend and Yes No
manage construction of the project?
Yes _ No
3 Do you intend to directly control & sY(
rvise c nstruction activities
Yes No
4 Do you intend to schedule contract Or irectly pay for all phases of
construction work to be done?
Yes N
5 Do you intend to personally occupy e bui mg for at (east 12 consecutive
months following completion of const. ction an do you understand that if
you do not do so it creates the pre mption and r 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 F. S 6 Months to 2 years permit re issue fee is $150 00 After 2 years re issue fee
is as per current feh le
Signature of Ow f r /Conti- 'tor /Officer(s) of Corporation D a t `L
te
Affidavit for Workers Compensation N C G S 87 14
The undersigned applicant being the /
General Contractor V Owner I/ 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
vacs one (1) or more subcontractors(s) who has their own policy of workers compensation insurance
covenng 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 tt �
Company or Name 1-C i-t. rt v L. 1 laiti
Signwfft / /� • Mr r /[ Il of Date :- tit_
1
Re d alB Ij gApO Gat om t
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