PERMITS yes _ uu I -
Certification of Work Performed fD O
By Owner/Contractor
- D Contractor Information / ' /
work on the project or
I, IKZFo~, Z-LK !%/t~ai l complete the l~
(Name) (Trade)
structure herein described. My state license number is . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: 467
Mailing Address: y' C-
Street Address: vE L~~E C
Business Phone: Email Address: A L 6z%'~~`t/hz~e,c
'Company name, address, & phone must match information on license.
Job Information
Land Owner's Name: fj Phone
Tenant/Building Owner(if different): Phone:
Construction or Site Address: /Z ~x /GL< ae ~i`~~yr~✓~G✓O-®~
PIN or Parcel # from GIS:
S ecific Dir lion t ob from L~lin ton: 2 - ~ v~i~
Ah
c
Descr tion of work to be done: z_ (J(J/ j~/its{ J L~~Job Cost: 70
echanica • New Unit With Ductwork _ New Unit Without Ductwork ✓Gas Piping -
ec 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other _
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater _
Permit Cost
Permit Fee: $ (calculated from fee schedule)
Mail In Processing Fee: $3.00 oer application
c)
Total Enclosed: $ z
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
n Lillington, NC 27546
Contractor's Signatur Date: ®Z d
DO NOT SEND CASH. C L TE APPLICATIONS WILL NOT B PR CESSED.
ioroe
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