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Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
www.harnett.org
Certification of Work Performed By Owner/Contractor
Owner (s) of Structure: 1 0~ 2 1.12.2 Phone: RIO 8g3-5`I
Owner (s) Mailing Address: I V 8 W O'*&%ikQ0
Fuaruw-)(ae-c%w 9L ~'lsac-
_ST
Land Owner Name (s): Phone:
Construction or Site Address:
PIN or Parcel
Job Cost: 1 912.oa Description of Work to be done T NS3a.\\-
Mechanical: New Unit With Ductwork ✓ New Unit Without Ductwork _ Gas Piping _
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other
Plumbing: WatedSewer Tap _ Number of Baths _ Water Heater _
Specific Directions to Job from Lillington:
i 1Ce 401"Koch }ouiarZ Vwor.a.~ G, a'l r'iNN Terra 6ttA orb WoQW;W Or.
Subdivision: \NOo~5N%P-0 Lot
I have provided or will provide the M R labor
(Contractors Name) (Trade)
on this structure. I am the building owner or hold a NC state _~I V H L license
(Trade)
number c li \17~ 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.
Structure owner(s) signature: Date:
Company Name: 'FQi ko ,nck AC- Phone: hl9-55.2APa3
Address: k-.. 5, Fu Aue. - a 4
County: \ 1 Os ne C ractor's License y L1 l a.
Contractor's Signature: Date: / 09
*Company name, address, & phone must match information on license.
12/06
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'""http://gistools.hamett.org/Freeance/Client/PublicAccess l /index.htrnl?appconfig=public 1 10/19/2009