TRADE
Application # Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-4759
www.hamett.org
Certification of Work Performed
By Owner/Con/tractor D
Owner (s) of Structure: H{~-T c~~~ ,,Z4e X42- .
Owner (s) Telephone:
Owner (s) Mailing Address: e c a 7 3 d / 11 J
Construction or Site Address: S - €,g~r/t-2- rr7
Job Cost: _
qjA
escription of Work to be done 5 pw r~~ ~.(fA.1
D
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other _
lumbing: Tap Number of Baths _ Water Heater
ltGVn t ,lLicea ~o 6'c4)
S ecific Dir cticns to Job from Lillin ton:
If" 7-
Subdivision: Lot #
I lye-PjV0A) !1/!I have provided or will provide the ~-lJm e3i/lJl~ labor
(Name) (Trade)
on this structure. I am the owner or hold a NC state `t~7iS license number
(Trade)
which entities 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.
Owner (s) signature: Date:
Contractor's Name: L 41' 7 0g/pA e-b f 1410 . Date: f O b
Address: !rr26;F77`~iti✓Fvt~D G a733r~q
County: Z-67;5- I
Contractor's License:
Contractor's Signature:
10/05