BUILDING (2) Application# • ' r
Each section below to be filled out
by whomever performing work Harnett County Central Permitting
Must be owner or licensed PO Box 65 Lillington NC 27546
contractor Address company 910 893 7525 Fax 910 893 2793 www harnett org/permits
name&phone must match
Q Application for Residential Building and Trades Permit
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Owners Name PO ) Date [Sill
Site Address 4410 GwanA Lsr WA's) 1c4C 4A"y uonns Phone 33(o 733-31°)
Directions to lob site from Lillington 4Q I 10 %c E ri t \e-s ) v,f n 2.co----\- oc 3
(o\\0.r I R--00A X caJ n 2\ mil k' Tn o cl ,o�\\o - L) oacS
( -5c5tQti W.e a 2n 9 r)
Subdivision co-\\0 4 \-^300 Q-A-0 \ Lot ‘Z 3 4- 1 < 2-
Description of Proposed Work �) �-0 PS .�nCQ #of Bedrooms 3
Heated SF Unheated SF Finished Bonus Room? Crawl Space Slab
(�Geen�eral Contractor Information ( c
0pSO\1fn0. C\OISS� `--E] I4f UL-.ON vl\�� b� -� Jrn
wilding Contractor s Company N NC"27X03 Telephone
` .\ \\M\ ie,� C ,�\Q.ol, coo\%\es\Ot..\ 12(-@ MSM Con
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Email Address
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Ignature of Owner/Contractor/Officer(s)of Corporation License#
Electrical Contractor Information
escril tlon QQf Work n ) C.00-13
Electrical
Service Size 2c1O Amps T Pole _Yes No
0-(11e-\\ --\ec\-C c -ii `710 -5a 3o
Electrical Contractor\s Company Name Te ephon ( � C M
\\ �, \P�*,cAo. �a-nc Gocmcv. QC. X5 Pay-100\Q-\ec�c,�@ "-
dd^res\ n. C n Q Emalo,C� IsH
Signatu of Owner/Contractor/Officer(s) of Corporation License#
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Mechanical/HVAC Contractor Information
De cription of Work , `n'e-` CS\eonCC
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Mechanical Contractor s Co an Name Telephone
3 443 sh�t�w ,'
Address Email Address)
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Signature=Aewner/Contractor/Officer(s)of Corporation License#
Plumbs g Contractor Information
De option f Work R�-`-^- �-5\ -C. # Baths
a 4-L. 5OecA-4)Itkf,r.hn5 c c (02.19-o\' 3
Plumbing ompany a 0 k Telephone
1191\ W 0\,--\-Y.-\C5 K� , y i�t� NL��s�o
Add s
Email Address
Signature of Owner/Contra or/Officer(s) Corporation License# -t lD
u _ Insulat on Contractor Information
Ins ation Contractors Company Name &Address Telephone
cct LArr\
NOTE General Contractor must fill out and sign the second page of this application
P d t318011 3 ulc I n 1 t7 8/10
Homeowners Applying to Build Their Own Home
Please answer the following questions then see a Permit Technician to determine if 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
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 that the construction will conform to the regulations in the Building Electrical Plumbing and
Mechanical codes and the Hamett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and if amy 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 a er current fee schedule
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Signature of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Workers Compensation N C G 5 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
Vas 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 /
i
_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 f
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 pnor
to issuance of the permit and at any time during the permitted work from any person firm or corporation
carrying out the work I
Company or Nave e /Lint C II is 1c •0414(110N
Sign w/Title f. 1 i Le r*
f ' Date n
Resid I al Bu Id] g Appl rat on 1 2 08/10