TRADE
Application #4 9 o Q
/
Please note if this roAss application Mail Harnett In application
is County Central Permitting 3
with open permits. part of aprog PO Box 65 Lilliegton, NC 27546
910-893-7525 Fax 910-893-2793
_yes no www.harnett.org/permits
Certification of Work Performed by Owner/Contractor
(Individual Trade Application)
I, Contractor Information
I, (r ho-de-s k i G h~ will complete the 14 VA e work on the project or
(Name) (Trade)
structure herein described. My state license number is ® 9 Q :;L . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
CompanyName:l~ iCP ~PfarCr 12Zf nc ~~e~j inr CD. Inc
Mailing Address: l = be Sn n C~
Street Address: I18Q'Robeian S+- Va,Je4,ev, 11&_ NC 22RO S
Business Phone: q10-423- 9`1611) Email Address:
'Company name, address, & phone must match information on license.
~1 Job Information
Land Owner's Name: A I p~ t, k t n S _Phone: q
I O` 3(0- ~i(o I j
Tenant/Building Owner(if different): Phone:
Construction or Site Address: 52r/ S ee C/ DSS _Df- 5pri m
L -ke. ML 223cib
C4 Q
PIN or Parcel # from GIS:
Specific Directions to Job from Lillinoton:
ay oa o ZTO O Vverhills Rd-Turn rieght Then Left into
onecross
Des ripiion-of-work-to-be-done: h ~n l1=?rlan-GO S-!DOcC--- - -Job Cost: - ` -
Mechanical: New Unit With Ductwork New nit W hout Ductwork CX 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: $ 56.00 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application For Electrical Permits with Progress Energy
we need the premise number provided.
Total Enclosed: $ 00
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box~b>
Li i t66nrNC 27546
Contractor's Signature: 11/7 Date:
DO NOT SEND CASH. IN OMPLE L/CAT/ONS WILL NOT BE PROCESSED.
TRADE 4/08
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