TRADE
Application # 69 9 %_5
Harnett County Central Permitting
PO Box 65 Lillington, INC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
www.harnett.org
Certification of Work Performed By Owner/Contractor
Owner (s) of Structure: (mP_V_u ;(\e_ kvAt 2,o^ Churc(, Phone: (510 yg~ - 3330
Owner (s) Mailing Address: l4 S C eeV_v; 11e C L.),-L r2J
Sir A.~ L-ake N. C , T 9 U
Land Owner Name (s): Phone:
Construction or Site Address. f 4 S C vee%u11\e Clnu~cl^ i~c)
PIN or Parcel
Job Cost;t<`(a00.60 D_escription;of Work to be done Dn T 3 Sto.~ kenL AQ_
Cow maser cl,, e-ot? - ~SDUrGQ i S ele r A { -
-AS-3 . o 0
Mechanical: New Unit With Ductwork "New Unit Unit Without Ductwork _ Gas Piping
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect - Other _
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater
Specific Directions to Job from Lillington:
YQ, mtke_ or 2o.{ 2 3 wt c~ i S r)T O{ a10 be-8fe_ yo u
het in(j qp~:= LA-kC
Subdivision: Lot
I N; r.+~~L Le have provided or will provide the labor
(Cdntractors me) (Trade)
on this structure. I am the building owner or hold a NC state U✓~( license
(Trade)
number 18 t~ 7 ,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 and local laws,
ordinances and regulations.
O~
Structure owner(s) signature: d+~ Date: 1 to 01 ob,
Company Name: 17, L_4 ~~o V +Wwk L" P !VC Phone: (Kt o) 7 ~r
Address: SSd E. 2.,I5se(( s1- - 52~t ,N_G, ~$161
County: w er)Kr..rJ Contractor's License l ~I S 7
Contractor's Signature: Date: R p
'Company name, address, phone must match information on license.
12/06
I