BUILDING Application # 1050024105
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Certification of Work Performed By Owner /Contractor
(individual Trade Application)
Owner (s) of Structure: Phone:
Owner (s) Mailing Address:
Land Owner Name (s): Phone:
Construction or Site Address:
PIN or Parcel # from GIS:
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping _
Electrical *: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other _
* For Progress Energy customers we need the premise number
Plumbing: Water /Sewer Tap Number of Baths _ Water Heater _
Specific Directions to Job from Lillington:
Subdivision: Lot #:
I v 1 ( will provide the me/ `— labor on this structure.
(Contractors Name) (Trrrade oA
I am the building owner or my NC state license number is 1 017"z-- , which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code
and all other applicable State and local laws, ordinances and regulations.
Structure owner(s) signature: Date: 5 rr
Company Name: G & M service Company Phone: 919 - 772 -8820
Address: 3317 Durham Drive, Raleigh, North Carolina 27603 County: Wake
Contractor's License #: 08892 Email Ad ress: sales @gandmservice.com
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Contractor's Signature: 02 • 7L Date: 06/04/2010
*Company name, address, & phone must match information on license.
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