TRADES
Application #
Please note if this application Mail In application
is part of a job in progress Harnett County Central Permitting
with open permits. PO Box 65 Lillington, NC 27546 ~~lal$`~ as
Telephone Number 910-893-7525 Fax 910-893-2793
yes _no www.harnett.org
Certification of Work Performed
By Owner/Contractor
1j - t- Contractor Information
I, fl~ClT ~O`(1f1S im will complete the t1 V fl C, work on the project or
(Name) (Trade)
structure herein described. My state license number is ~9 t (0 4~. All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
CompanyName:
Mailing Address: Ln la
Street' Address: A M
Business Phone: q~ -550(" Email'Address:7VM 733q A01.CA
'Company name, address, & phone must match information on license.
Job rmation ~y 10 I _ , l
Land Owner's Name: y~ ~L~1~An o Phone. _1 'l ~3 III
Tenan Building Owner(if different : Phone: qk0-Lt01-UQA
Construction or Site Address: au M
PIN or Parcel # from GIS:
S e kil Directions to orb from Lillin o5 njp ~ A-~
`t'~l T t ~J IK,J
2 p &7%ouF On (k)
Description of work to be done: ViW(1R~1 .11V~IG ~~u~ Job Cost:
-to
Mechanical: New Unit With Ductwork _ New Unit Witho t Ductwork Gas Piping _
Electrjcal: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect - Other
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater
Permit Cost
Permit Fee: $ ~D5 e ()O- (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ LD% , Oo
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: Aid Date: (66
DO NOT SEND CA INC MPLETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
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http://gistools.harneu.org/Freeance/Client/PublicAccess 1 /index.html?appconfig=public 1 4/12/2010