SETUP
t~ 1
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number: 910-893-4759
Application for Manufactured Home Set-Up Permit
(Please fill out each Part completely)
Part I -Owner Information:
Home Owner Information (To be c,k ompleted by owner of the manufactured home)
Name: Q-A /~f pil / Address: /0 l/il<~I C,2~'4
City: ~E401-04- State:/4/,~-• Daytime Phone: Pi) ~S 6 aaa f
Landowner Information (To be completed by landowner, if different than above)
Name: Address:
City: State: Zip: Daytime Phone: ( )
Part II - Contractor Information (To be completed by Contractors or Homeowner, if applicable)
A. Set-Up Contractor Company Name:_ State Lic#
Phone: Address:
City rState* Zip:
Signature: bi
B. Electrical Contrdc oe Com ny Name:~P State Lic#
Phone: Address''
City: te: ~ Zip:
Signature:
C. Mechanical C~Jractor Co pang Name: State Lic#
Phone: Address:
City: State: Zip:
Sianature: 9zm
D. Plumbing Co r or Company Name: State Lic#
Phone: Address:
City: S We: Zip:
dSianature: ~titi,
Part III - Manpuufactured Home Information
_New r/Used
_Singlewide _t4ublewide _Triplewide
Model Year: e:2 6 Size-1--De
Xp
Private Property Manufactured Home Park
Park Name: Lot Number:
Directions to site or from Lillington:
I hereby certify that I have the authority to apply for this permit, that the application is correct including the
contractor information and signatures, and that the construction or installation will conform to the
applicable manufactured home set-up requirements, and the Harnett County Zoning Ordinance. I
understand that if any item is incorrect or false information has been provided that this permit could be
re>v
Signa re of Owner or Agent Date
'Effective my 1, 2004, a Harnett County Tax Department Moving Permit must be purchased before a Set Up Permit will be issued.
06/04
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