TRADES
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Please note if this application Mall In aDpIICBYIOn Application #Q9 7
is part of a job in progress Harnett County Central Permitting
with open permits. PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
yes _no www.harnett.org
Certification of Work Performed
By Owner/Contractor
/ Contractor Information
1, G hs will complete the _J1111f CZ61tcf work on the project or
(dame) (Trade)
structure herein described. My state license number is . All work shall comply with the _ZZ /.ra y5' y
State Building Code and all other applicable Statee & Local law, ordinances and regulations.
Company Name: i~o Ile e /a- Ke- 1 G (l C ZU
Mailing Address: _ /'O W ar X ?'T / 4-,
Street Address 0/,'yam 4e Rte/
Business Phone: 5W - '/dil`-(D/7y Email Address: llo/leae &1e r zjq
'Company name, address, & phone must match information on license.
Nr f-
N ~h J b Information
Land Owner's Name: P~ e. n T s Phone
Tenant/Building Owner(if different): Phone: /
Construction or Site Address:_y(o -4 k/r 4 s e d ~f.~
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Specific Directions to Job from Lillington:
s m F''i L~ L
c o ~ ~ ,o
Description of work to be done: /t d crS 9 u cr : Job/-
Cost-
Mechanical: New Unit With Ductwork Ne Unit Without Ductwork _ Gas Piping
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect Other
Plumbing: Water/Sewer Tap _ Number of Baths - Water Heater
,,rr~~ Permit Cost
Permit Fee: $ /00 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed:
Make check payable to: Harnett County Central Permitting (HCCP)
Mail completed application form to: Harnett County Central Permitting
PO 65
L~ i 27 6
Contractor's Signature: 4
DO NOT SEND CASH. INCOM TE APPLICATIONS WILL NO BEPROCESS
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