SETUP Nov 04 10 09:45a Tammy Williams 910- 892 -4071 p.2
Application # 1050 O a 1 n 3
Harnett County Central Permitting
PO Box 65 Lilfington, NC 27546
;✓lk Telephone Number: 910-893-7525 Fax 910- 893 -2793 www.harnett.org /permits
Application for Manufactured Horne Set -Ua Permit
(Please fill out each part completely(
Part 1 -Owner Information:
Home Owner Information (To be completed by owner of the manufactured home)
N me
ame:t _CuEr `?Y`!tv'l�F Address: Pc: e1OX 13
r�
City: \ / t .kYm .n State: 14 C Zip Daytime Phone:Vq0 K5' i t 3M
Landowner Information (To be completed by landowner, if different than above)
Name: Address:
City: State: Zip: Daytime Phone: ( ).
Part II - Contractor Information (To be completed by Contractors or Homeowner, if applicable.
Name, address., & phone must match information on license)
A, Set - Up Contractor Company Name: rno nmo r S
C
qS FVG v 7�l
Phone: /, l � � �r�( Address: - tc (iv (
Cit 1. L.A.0 n State: Zip: a .3 3 4
Setup Sianatur; - a-_ State Lic# 3 t 0
B. Electrical Contractor Company N e: -
Phone: Address:
City: State: Zip:
Electrician'S Sianature; State Lic# A
C. Mechanical Contractor Company Name: ra'• pr, it 14t%4T tail 4.o tie
Phone:a Address: CO , .4n A /94 r anky
Cit y: (1, State: N r Zip: ?. 7 S 7 )
HVAC Signature: State Lic#
SCrare
D. Plumbing Contractor Company Name: II - � A • u-''''t b� 4 J - poe ,�J
Phone: 91 R -Qr b -off Address: 7�`!' gJ t" Okav* t�
City: State: ( / Zip: 24314
Plumber's Sianature: &. W "4-- State Lic# /tl.43g
Part 111 - Manufactured Home Information
Model Year: 1 a l ( Size :c _X Complete & follow zoning criteria sheet
Park Name: Lot Number:
1 hereby certify that I have the authority to apply for this permit, that the application is corrt including manu t co n t hom or
information and signatures, and that the construction or installation will conform to the applicable
information hem eeen r provided that Harnett
ar n ets permit c oulning Ordinance. I understand that if any item is incorrect or false
-
Signat �
r .
o Home Owner or Date - nt
'Effective July 1. 2004, a County Tax ()enactment Movina Permit must be provided before a Set Up Permit will be issued.
purchased from the fax office of the county that the home is moved from. If the home is from a dealer, we need proof of year on the
Form 500 and if available, the serial number.
List of inspections and Egress requirements available upon request. Progress Energy customers must provide Premise Number.
4/08
SETUP