TRADE 07/16/2009 15:08 0000000000 PAGE 02/02
Application
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permfts
Certification of Work Performed By Owner/Contractor
I (Individual Trade Application)
Owner (s) of structure: 10 -e Phone:9/0-&V -a/
Owner (s) Mailing Address: fC U- ar 7
i1
yvj
Land Owner Name (s): SG1it Phone: f~ r
Construction or Site Address:- .~0 Q (t ea 1C) akc ~Y3~m yncd .
PIN or Parcel #from GIS: r~ p
Job CosC' bw description of Work to be done ~sL~~ Q - 1:t. S 4Cx_
_ _ , n ao~~ p irwfl ~g~X~, . . D t rr+ utoQ_ 1~
Mechanical: New Unft With Ductwork JZ*New Unit Without Ductwork _ Gas Piping
Electrical': 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other
'For Program Energy customers we need the premise number
Ptumbing: Water/Sewer Tap_ Numberof Saths_ WaterHeater_
cftto Dfreoti n to Jo from Lill!maton:
Subdivision:
f I Lot
I Sn.a m~ ~-g ca) r~will provide the labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is as , 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 an local laws, ordinances and regulations.
Structure owner(s) signature: C Date
/r
Company Name: Phone: - `f !-5
Address:
County: Cont ctor's License M
Contractor's Signature: Q a Date: /
`Company name, address, & phone must match Information on license.
TRADE 4/08