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9108932793 Narnott Cotrty Planning MRK-rT co. PUNNING SERVICES 14:19:57 11-01-2007 112
Application # 0 r ~ O
Pleawnoteif this application Mail In application 7~D !iG
is pan ofa job in program Harnett County Central Permitting
with op9n pmaits PO Box 65 Lillington. NC 27646
Telephone Number 910-893-7525 Fax 910.893-2793
-yes _no www.hamett.org
Certification of Work Performed
By Owner/Contractor
Contraeta Information
I, l~RX k QN 2A will complete the a work on the project or
(Name) (Trade)
structure herein described. My state license number is UAIo k All work shall comply with the
State Building Code and all otherapplioeble State & Local law, ordinances and regulations,
Company Name:. -%roniLO ~r 50Aa t% N~ a "ac, 10kr _
U
Mailing Address: cc /J
Street Address: $;Zl \ C(~[►ma U-4 4 Nr ' VA%n" L&r
Business Phone: at Q-1A- A- -71DQ'6, -Email Address;
'Company name, address, & phone must match information on license.
Job Information Land Owner's Name: Q~Qt-I r.I Phone• FStoSs-z) z1
Tenant(Buliding Owner(ff different): f[%Q i)t H-, Pkxrll~l P one' _
Construction or Site Address: n b t. 3-1 y L 1 1.1 t ~-1 g
PIN or Parcel # from GIS:
Specific Directions to Job from Liliington:
Description of work to be done: Jo Cost: O
Mechanical: New Unit With Ductwork __l New Unit Without Ductwork Gas Piping
Electrical: 200 Amp _ X200 Amp _ Service Change _ Service Reconnect _ Other
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater T"
- Permit Cost
Permit Fee: $ (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: S
Make check payable & Mail completed application form to: Harrell County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: - - Date:
DO NOT SEND CASH. IN OM ETE APPLICATIONS W1LL NOT BE PROCESSED.
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