TRADE
Application #
Please note if this application Mall In application
is part of ajob 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, Y" C S will complete the IV AC le work on the project or
me) (Trade)
structure herein described. My state license number is 7 . All work shall comply with the
/soyv 41
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: 176 /l e a l e- c 0 L11 r)
Mailing Address: ~1 ~SS ax / ! a Ale ~
Street Address: d d Y Q /L /iA za hr7 Li 4or~ rt
Business Phone: F/d - wl/7 0 Email Address: 2o
`Company name, address, & phone must match information on license. N e
ob In rmation
Land Owner's Name: A r yt S C ~ Phone: QQ
Tenant/Building Owner(if different : e4l 1q Phone: - 3 ;74
-
Construction or Site Address: 5/ eeu4 r ofo2✓ .~o~rJQrN/ VC,
Specific Directions to Job from Lillington:
a 4 r/ `~L~t
v/4 of Ac Re eo inee CleOL
Description of work to be done: Cn•tde^J ,,'ag c,l I' L Job Cost: WA %0
Mechanical: New Unit With Ductwork Nekv Unit Without Ductwork ' Gas Piping_
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect - Other
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater
Permit Cost
Permit Fee: $ /00 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ y3
Make check payable to: Harnett County Central Permitting (HCCP)
Mail completed application form to: arnett County Central Permitting
Box 65
ton, NC 27546
Contractor's Signature: Date: /0 q
DO NOT SEND CASH. INCO ETE APPLICATIONS WILL NOT BE PROCESSED.
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