TRADES Application #40 if 0(3
4 Harnett County Central Permitting 4/4390
PO Box 65 Lillington, NC 27546
y - 910 - 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Certification of Work Performed By Owner /Contractor
(Individual Tra Application) q /� 2
Owner (s) of Structure:
____,...40
i. At t / Phone: / �0�9� �� 3 / >
Owner (s) Mailing Address: a - "j ./. _!l,. r AP i, _ sr
Land Owner Name (s): .e�4 Phone: 9JP S 7 5T 23
Construction or Site Address: // :at e► .. ,_ l C
PIN or Parcel # from GIS: ,r! .. r ti. .. ,
Job Cost: Description of Work to be_done ` S r?``" c t. ( c o,-JAI tCT
Mechanical: New Unit With Ductwork _ Neyv�,U9 t 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
S•ecific Directions to Job from Lillin•ton: „__-,
Subdivision: Lot #:
I n �
I .i 1Y (,4 e 1 eC1f' ( Cn ,will provide the e kp(At i (A l labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is q �) - (.( , 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: 9ta . Y) l4- Lco Date: -5 /i 2,9 / O
Company Name: (A rn 14-r 4 f < leA r ic Gi, Phone: (f? 1 3/4
Address: PO. 5i y P A a Orgy) N
County: Contractor's License #: 4 13a l -Ii
Contractor's Signature: Date: 5 / G/ 2-0/ r
'Company name, address, & phone must match information on license.
TRADE 4/08
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