TRADES (2)
Application #
Please note if this application Mail In application
of ajob i progress Harnett County Central Permitting
is with pert oopen ob permits. PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
✓yes _ no www.harneft.org
Certification of Work Performed
By Owner/Contractor
Contractor Information
I, "Y+ &*01 Norr"< will complete the k EL4ri e l work on the project or
(Name) (Trade)
structure herein described. My state license number is IUM SP-SFD All work shall comply with the
Stater8aildhrg;Ga0e ahd ail otfier-applicable StataZ Local law, ordinances and.regulations. LL
Company Name:
Cumberland Electrical ervlce
Mailing Address: 1725 joi net: M.
Street Address: € r W G 2R242
Business Phone: (910) 920-1166 Email Address:
"Company name, address, & phone must match Information on license.
Job Information
Land Owner's Name: AoioeA kp tl r Phone: 141-350-HoW
TenantlBuilding Ownerpf differenfl• Phone:
Construction or Site Address: '881 &adn ni n U. )a, t ~)a hinM NCI a)3" a.
PIN or Parcel # from GIS:
Specific Directions to Job from Lillinoton:
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nl nn 1 Jnyta iS )n Le4f-
Description of work to be done:A -rer= -A W1;+Sfi4rjna hex+Paojob Cost:
- Mechaniea)- Nev 4Jn t-With-Ductwork . New-1JnR-Without-0uctwark _ -Gas-P_iping
Electrical: 200 Amp _ <20O Amp _ Service Change -Service Reconnect -Other
Plumbing: Water/Sewer Tap ^ Number of Baths _ Water Heater _
Permit Cost
Permit Fee: $ 50,00 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ 53,00
Make check payable 8 Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Li lington, NC 27546
Contractor's Signature: Date: l fit- 3 - Q9
DO NOT SEND CASH. INCOMPL -T - APP CATIONS WfLI NO BE PROCESSED.
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