BUILDING' Each section below to be filled out
by whomever perlorming work.
Must be owner or licensed
contractor. Address, company
name & phone must match
Application #
Harnett County Central Permitting
PO Box 65 Lillinglon, NC 27546
910-893-7525 Fax 910 -893 -2793 www.harnell.orgtpermits
Application for Residential Building and Trades 'Permit
Owner's William Wellons, Jr Date:
Name: William
Address: Phone:
Directions to job Site from Lillington: Highway 210 S approximately 10 miles, turn right on Bill Shaw Rd go .6 miles,
tum left on Ouerhills Road go 2.7 miles, sharp left on Ray Road go .4 miles, right on W Northpoint Rd —T--
l o l Ytr L
Subdivision: COOPER'S CREEK Lot:
Description of Proposed Work: # of Bedrooms:
ine
Heated SF:24-_4 Unheated SF: 552— Finished Bonus Room? - tJ Crawl Space: W Slab: n
General Contractor Information
CAVINESS & CATES
Building Contractor's Company Name
639 EXECUTIVE PLACE
Address
59586
License #
Description of Work RESIDENTIAL
PARNELL ELECTRIC
Electrical Contractor Information
Service Size:
Electrical Contractor's Company Name
6167 STEWART ROAD, GODWIN NC
Address
24236 -U
License #
910 -481 -0803
Telephone
Email Address
Amps T -Pole; —Yes —No
910 -237 -2751
Telephone
Email Address
MechanicallHVAC Contractor Information
Description of Work RESIDENTIAL
TOTAL SYSTEMS HEATING & AIR 940- 436 -3450
Mechanical Contractor's Company Name
13341 HYW 210 S. SPRING LAKE NC
Address
28846
License #
Description of Work
American Plumbing
Plumbing Contractor Information
Plumbing Contractor's Company Name
3715 Auburn Church Road, Garner NC 27529
Address
13228
License #
Insulation Contractor Information
Telephone
Email Address
# Baths
919- 772 -1346
Telephone
Email Address
0tirn6e10lJ -- asljeoh 110-4 I �(R
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
Please answer the following questions Shen see a Permit Technician to determine if you qualify for permit under Ovmers Exemption.
Questionnaire per G.S. 87 -14 regulations as to Issue of Building Permits (Memo avalable 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. Edo 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 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 FEES - 6 Months to 2 years permit re -issue fee is $150.00, After 2 years re -issue fee
is as per cu �nt fe schedule.
X0.13 -11
Signature 6iZWKe rfContractor /Off ice r(s) of Corporation Date
Affidavit for Worker's Compensation N.C.G.S. 87 -14
The undersigned applicant tieing 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.
Has one (1) or more subcontractors(s) who has their own policy of workers' compensation insurance
c vering 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. y
Company or Na
Sign w/Title: Date: k}`
8121108