TRADES
03129/2004 09:12 9108932793 HAR NETT COUNTY PI PAGE 01
/O 600
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910.893.4759
MATT. IN APP]r[( Anon FD=
CERTIFICATION OF WORK PERFORMED
~ tl L`ONTR 4I'.TY1R RJP(1RMk770N
1, .(Name), will complero the 1~ 4t 7~ i Yi (trade)
work on the projector stun hemin descn My state license member is /,(n
Work on this project or etruewre shell moat all applloable codes.
Comyany Name:
Meiling Address: ,:I t/ -,/7, C, -1-9 3
BusinessPiwne: _
lQS~QB>1~TT1?ZI
Harnett County Application Number:
Tenant'c Name:
Land Owner's Name:
Address of jab: 202 S
Directions to job Bite from Lillington, NC (be specific):
Date Work is to Begin:
PHRMIT C03T
Pamtlt Fee: S &V (calculated ftorn fee schedule) Number of Tons
Processing Fem $3.00 per application q~G~ ~ ow many tmlm
TOTAL ENCLOSED: 5 lV3 ~ / Soy✓'fx.~r
Make obeck payable to _ Harnett County Planning Department and mail with completed application form
to:
Harnet County Central Permitting
PO Box 63
Lillington, NC 27546
DO NOT SEND CASH. INCOMPLETE APPLICATION WILL NOT BE PROCESSED.
Contractor's Signature: r Date: z-~4
PLEASE INCLUDE DESCRIP'T'ION OF WORK:
02101
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