TRADES 03/29/2004 09:12 9108932793 HARNETT COUNTY PI PAGE 01
Kamen County Central Permitting
PO Box 65 ',Ellington, NC 27546 •
Telephone Number 910-893 -4759
MATT, IN AJPU('ATJON FORM
CPRTTFICATION OF WORK PRRFOR sirup
CONTR 4fTOR TNpe1RMATTON
i, `1)1 id<;G �/ (Name), will complete the (feat Y 4----;4_-(tra4----;4_-(trade) ;(trade)
work on the project or Met= herein described. My state license number is
Work on this project or strut:nun shall meet all applicable codes.
Company Name: ,1/$
Mailing Address: /i• � r�. --
- Business Maw - - - — - - -- -
IOB_D4FflRMATlON
Harnett County 4ikatigQn Number: •
Tenant's Name: .1 Y A 00 -4tr% 1den c
Land Owner's Name:
AddressofJob: '�'G'S' dQnYf 7/414/,
Directions to job site from Lillington, NC (be specific):
Date Work is to Begin: Y- oiel -14
Permit Fee: $dab. (calculated from fee schedule) Number of Tons _$
Processing Feet $3.00 per application How many units /
TOTAL ENCLOSED: $ /i)1. ` c) -
Make check payable to : Harnett County Planning Department and mail with completed applleadon torte
to: -
Harnett County Central Permitting .. -
PO Box 65
Lillington, NC 27546
DO NOT SEND CASH. INCOMPLETE APPLICATION WILL NOT BE PROCESSED. .
Contractor's Signature:4ir /�Q/ Date: «/ Z & /C)
PLEASE INCLUDE DESCRIPTION OF WORK:
04 OLt - 46;' ff �r . p. / 14) ti- 1), -`-4d o
02/01
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