TRADE . _~+<>e-•.~.-.c; ;~-«<a-~.-:Vim.:±~^~{a..a7q°~''"'"cfrwx±a. _ +n.••"'r' -w - - .9m:sr~rsg
Application # 9 Db
Please note if this application Mail In application -
a' 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.hamett.org
Certification of Worts Performed
By Owner/Contractor
Contractor information
1 C~.v i t 2 KTc -(-4('4c. will complete the P1 Fc 4"' ` c'q 4'- work on the project or
(Name) (Trade)
structure herein described. My state license number is `f 6 Z-2 . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: f~7-6 t•- f7~C
Mailing Address: E- tirirr S ✓ 4 v~cR 4 N c 27932 -
Street Address:
Business Phone: 9 9 - 77~ - 2 Email Address: c e,-(e r4rQ?1& c ✓~f^e„^^ - .,ef
"Company name, address, & phone must match information on license.
Job Informatio
Land Owners Name: Or'~C"~ -Ge e~ Phone: 9i9- X99-4~6z~
Tenant/Building Owner(if different): Phone:
Construction or Site Address: q- 3Y- 01-1vz" /"c z'7-737-
PIN or Parcel # from GIS:
Specific Directions to Job from Lillington:
H•lr ~G/•'I ~1 TO JfjN (-O/r /f 1 JGN ('7 /~"'/.1'/~ ~JLj 7~'/qN .7
ocrvz-,a A Go .F %Re F/oMe a 5AA cvE Aw ?t/e~s
A-J flare TIN /r004
GAS PAC (c - w;-71
- Descriptiorrof work to ba done 14'A^E~ Job Cost:
_ --:Mechanical:-- New Unit With Ductwork _ New 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: $-U, 0 a (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ %3 oa
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: ki. 1t~ Date: le-11-01'
DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
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