Fillable JACKSON COUNTY PERMITTING & CODE ENFORCEMENT Accessory Use (Jackson County)

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JACKSON COUNTY PERMITTING & CODE ENFORCEMENT Accessory Use (Jackson County)

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DATE REC’D: __________________________
Office Use Only: B E P M W
PHONE:
LIEN AGENT REQUIRED?
PROPERTY PIN NUMBER:
NAME:
ADDRESS:
NC LIC #
PHONE:
NC LIC # PHONE:
NC LIC # PHONE:
BUILDING CONTRACTOR:
ELECTRIC CONTRACTOR:
PLUMBING CONTRACTOR:
MECHANICAL CONTRACTOR:
NC LIC # PHONE:
TYPE OF CONSTRUCTION: Wood Frame
Metal Masonry Modular Log
LAND USE: Residential Commercial Garage Storage Workshop Other
Total Number of Rooms Description of New Work:
Bathrooms
Heat Type(s): A/C:
No Decks: No
Fireplaces:
No Yes
# Fireplace(s):
Yes Yes
Chimneys:
No Yes
# Chimney(s):
Square Footage Details:
1
st
Floor
2
nd
Floor
Total Cost of C onst ruction: $
Basement
TOTAL SQ. FOOTAGE
sq. ft.
(DETAILED DIRECTIONS TO JOB SITE-IF POSSIBLE, PLEASE INCLUDE A 911 ADDRESS)
POWER PROVIDER: JOB # (if Duke Energy):
I hereby certify that all information in this application is correct and all work will comply with the State Building Code
and all other applicable State and local laws and ordinances and regulations. The inspection Department will be notified
of any changes in the approved plans and specifications for the project permitted herein.
SIGNATURE:
DATE:
JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Accessory Use Building Application
Sylva Office: 401 Grindstaff Cove Road, Suite 145, Phone: 828
-586-7560 / Fax: 828-586-7563
Cashiers Office: 357 Frank Allen Road, Phone: 828-745-6850 / Fax: 828-745-6867
YES
LIEN ENTRY NUMBER:______________________________
You may submit a completed, signed copy of this application to our office in person, by fax, or e-mail to
jcpermitcenter@jacksonnc.org. Fees may be required.
CITY:
STATE:
ZIP:
E-MAIL ADDRESS: ________________________________________________________________________________
NO
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Confirmation of subcontractor for: (job name)
General contractor name:
IF PERMIT IS GRANTED I AGREE TO CONFORM TO ALL LAWS OF THE STATE OF NORTH CAROLINA REGULATING SUCH
WORK. I CONFIRM THAT THE INFORMATION LISTED BELOW IS TRUE AND ACCURATE.
Electrical Contractor
Notary Public Information
Contractor Signature
Notary Public Signed
Printed Company Name
Commission Date
NC License #
Phone #
Contractor’s E-
mail
(Notary Seal)
Date Signed
County/State Signed In
Plumbing Contractor
Notary Public Information
Contractor Signature
Notary Public Signed
Printed Company Name
Commission Date
NC License #
Phone #
Contractor’s E-mail
(Notary Seal)
Date Signed
County/State Signed In
Mechanical Contractor
Notary Public Information
Contractor Signature
Notary Public Signed
Printed Company Name
Commission Date
NC License #
Phone #
Contractor’s E-mail
(Notary Seal)
Date Signed
County/State Signed In
JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Confirmation of Subcontractor for Permitting
Sylva Office: 401 Grindstaff Cove Road, Suite 145, Phone: 828-586-7560 / Fax: 828-586-7563
Cashiers Office: 357 Frank Allen Road, Phone: 828-745-6850 / Fax: 828-745-6867
Per North Carolina General Statute 87-14
The undersigned applicant for Building Permit # ________ being the
______ Contractor
______ Owner
______ Officer/ Agent of the Contractor or Owner
do hereby aver under penalties of perjury that the person (s), firm (s), or corporation (s) performing
the work set forth in the permit:
______ has/have three (3) or more employees and have obtained workers’ compensation
insurance to cover them,
______ has/have one or more subcontractor (s) and have obtained workers’
compensation insurance covering them,
______ has/have one or more subcontractor (s) who has/have their own policy of
workman’s compensation covering themselves,
______ has/have not more than two (2) employees and no subcontractors,
______ has/have applied for permit where the cost is under $30,000 and I am, therefore, exempt
from Licensed General Contractor requirements specified by G.S. 87-14,
while working on the project for which this permit is sought. It is understood that the Inspection
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.
Firm name: __________________________________ By: __________________________________
Signature: __________________________________ Title: __________________________________
Sworn to (or affirmed) and subscribed before me in ____________________________ County, this,
the ________day of __________________________, 20_____.
Notary Public: ____________________________ Signed: __________________________________
Printed Name Signature of Notary
My commission expires: _______________________________
(SEAL)
JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Affidavit of Worker’s Compensation Coverage
Sylva Office: 401 Grindstaff Cove Road, Suite 145, Phone: 828-586-7560 / Fax: 828-586-7563
Cashiers Office: 357 Frank Allen Road, Phone: 828-745-6850 / Fax: 828-745-6867
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JACKSON COUNTY PERMITTING & CODE ENFORCEMENT Accessory Use (Jackson County)

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Completed 14 December 2020

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