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Please note if this application Harnett County Central Permitting
is part of a job in progress PC Box 65 Lnington, NC 27546
with open permits' 910- 893 -7525 Fax 910 - 893-2793
www.harneu.orglpsrmits
Certification of Work Performed by Owner/Contractor
(Individual Trade Application)
Cottirastor IttMnraation
1, Pall Chi trc h will complete the Mefhnni en 1 work on the project or
(Name) (Trade)
structure herein described. My state license number is 2.41104 . All work shall comply with the
State St llding Code and all other applicable State & Local law, adnances and regulations.
Company Name: c Seta 5 AC I dolt ,
w .
Mailing Address: 21a3t SitsclekONFIrs dr. Vrt 3 0na M to MC. 213D\1,
Street Address: ; ' ti • _ _� _ ‘_. _ '•. _AI
Business Phone: GO 8108 _102CAL Email • . . : 1Cl Yt•h(ab al.Cotlni
'Company name, dress. & phone must march hdonnarbrt on Iaxnse.
Land Owner's Name: SkAneCX\ ( a� ec Phone:q C ° *..0 – Uy�LP
Tenant/Building Owner{d different): Phone:
Construction or Site Address: Q\ r a` r • a A = D . 0
PIN or Parcel # from GIS:
Saecific Directions to Job from LWtnnton:
- ' t 54. , �t>t±.u�a'�.1ir► Lin h . • �.
• - .. r . • 'firre ... . r bn
2,_^ c�
Description of work to be de: I RCO�ft C e ' l \P 0.\ Puri prop cost: 7 H
on – 1 '�_
Mechanical: New Unit With Ductwork_ New Unt Without dF AL Gas mp —
Electrical: 200 Amp <200 A _ Service Change _ Service Reconnect _ Other _
• 'Phirrbing Water/Sewer Tap _ Number of Baths _ Water Heater —
�C
Permit Cost
(05
Permit Fee: $ . (calculated from fee schedule)
Mail In Processing Fee: $3.00 aer ang eatlwi For Electrical Permits with Programs Energy
va we need the premise number provided.
Total Enclosed: $ 0 ZS
Make check payable & Mad completed application torn to: Harnett County Central Permitting (I:^.CP)
PO Box 65
Liab.Jluwt.NC27546
Contractor's Signatu -. • L' Date:
DO NOT SEND ; - INCONPL .PPLICe47YONS WILL NOT a
TRADE 4/08
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