TRADE
Application #
~f V ju, ' Ha nett County Central Permitting .L ~2 `7 , j l
PO Box 65 Lillington, NC 27546
U' Telephone Number 910-893-7525 Fax 910-893-2793
www.harnett.org
Certification of Work Performed By Owner/Contractor
t~(7wncr (s) of Structure: Phone:
Owner (s) Mailin A dress:
.Land Owner Name (s): t n(~ I e it L, t-, a i.l Phone: qit)-Y,~j~-
~C~o~pstructionorSite Address: sg-o nn'cY-C~ TnUPC: RA L.ilGng4Zn.NCa7SY/o
~d PiNort~rrj _c ItooL~
OLIN ost: Description of Work to be done
Mechanical: New Unit With Ductwork - New Unit Without Ductwork _ Gas Piping _
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater
Specific Directions to Job from Lillinaton:
Subdivision: H ij 1 1 < <Sr_c~ yna Lot ~L}/JU~,/
_ have provided or will provide the ( labor
( s Name) (Trade) J
on this sAWe I am the building owner or hold a NC state ~NrLI~~ license
(Trade)
number which entitles me to perform such work on the above structure legally. All
work shall comply with the State Building Code and all other applicable State and local laws,
ordinances and regulations.
-4ructure owner(s) signature: Date:
Company Name:
Address:
County: nse
Contractor's Signature: -Date:
`Company name, address, & I ion on license.
12/06