BUILDING Ea h 1 hel wtobefill d utby 1U r� PC 2 / Li L_ H^-
wh m e perfo m ng wo k Must be own APPji�ltliln# rrr J l�
Ice s d c tractor Address company
name&phone must match nformation on Harnett County Central Permitting
I PO B x 65 Ltllmgton NC 27549
Ph n 910 893 7525 F 910 893 2793 www ha ry
AA lifor Residential Building and Trades Permit
Owners Name Im.,‘"Gq>n Welcp.rntin} Date i/ R I)
Site Address 9S0 Co1(esrwv Y&vk r,a
Vae. Phone IV) 43q 4 07.3
Directions to job site from Lillington w0 DcJ• Cit 1
L f1 t v tS4 nx1 *•
UIVVI L taeslDwel a 'SI on .1(eSk1Nrti Pe
e. ^�1 1
Subdivision l,Qke S 15 v,.rN (, r flX�'C Lot -(q
Description of Proposed Work \\Mesta to n1/24 Nom° '( #Bedrooms 3
Heated SF i I"16 Unheated SF Finished Rec Roomy NO Crawl Space (.Slab ( )
General Contractor Information
ctanr•i1 Minders . Tnrr . 919-649-9079
Building Contractors Company Name Telephone
-14 466 S . n 1 Rd An• ier NC 27501 034533
License #
i"A' g' lletni 2. Must sign &fill out second page
gnature of Owner on l 'tor/Of - er(s) of Corporation
glectrical Permit Information!
Description of Work New Rec tdentlel Service Size 200 Amps TPole yes/no
Stancil-Owen Electrical , Inc 919-639-2073
Electrical Contractors Company Name Telephone
s•tancil R• • ngie / NC 27501 13075-L
• cdre
License #
i' _ma a I r
Sig_1i of Offic_, s) of Corporation
Mechanical Permit Information
Description of Work Residential
JC s Heating & Air 919-552-6258 n
Mechanical Contractors Company Name Telephone
15:9 Wade Stephenson #oily Springs NC 12655-H3
Add ss License #
A.
Sign. ure .1 Offic:.r s) • e•rporation
Plumbing Permit Information
Description of Work Residential
# Baths
Barnes Plumbing Inc 919-639-0935
Plumbing Contractors Company Name Telephone
PO Box 1207 Angier NC 27501 P17735
Address License #
Signature of ff cer(s) o--s. f Corporation
Insulation Permit Information
Insulating , Inc , 1212 Home Ct , Raleiah, NC 919-772-9000
Insulation Contractors Company Name 8 Address
27603 Telephone
Page 1 of 2 9/07
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Application#
Homeowners Applying to Build their Own Home
Please answer the following questions then see a PermitTechnician to determine if you quality fgr 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 superintend and manage cnnstruction 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'r 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 dp sd it creates the
presumption under law that you fraudulently secured the permit? i
i yes no
--1- —
I hereby certify that I have the authority to make necessary application that th application is correct
and that the construction will conform to the regulations In the Building El ctrical 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 it any changes occur Including listed contractors site plan
number of bedrooms building and trade plans Environmental Health permit chOngbs or proposed use
changes certify it is my responsibility to no y the Harnett County Central PartinItting Department of
any and II changes / /
i'c, -(11( . r / motel i
Signature of Owner/Contracto /Officer(s) of Corporation Date
Affidavit for Worker s Compensation N C G $ 87 14
The undersigned applicant being the
X General Contractor Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) firm(s) or corpdration(s) performing the work
set forth in the permit
X Has three (3) or more employees and has obtained workers compensation Insurance to cover them
i
Has one (1) or more subcontractors(s) and has obtained workers comPensation insurance to cover
them
X 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 workers 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
i
Comp.•• or Nam: / dello]. des Ii• /�
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Sig n .. • e iii/�///a'/�/P esider>(�te 2 It
i/fse�
'tee
Page 2 of 2 9/07