TRADES yes "" Certification of Work Performed
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By Owner /Contractor
Contractor Information Q? & ^ 1
I, JO re if-Cb %ellhfc complete the 7 9777?---c --- work on the project or
(Name) • / (Trade)
structure herein described. My state license number is O (s c%w41.. All work shall comply with the
State Building Code and all other applicable State & Local law,, ordinances and regulations.
Company Name: 0 5 Ue-/ 1974 2,1-C
Mailing Address: //C < 1.-,J4/1 c 1-49 5 f-0 AZ 2 7-....??Q__
Street Address: 7 , -.A.S.
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Business Phone: 9/y ('"9/gd Email Address: Alci 4 0 / , e-c/
'Company name, address, & phone must match information on license.
Job Information
Land Owner's Name: r �/ /_ 77 1 ? /
i��T�/� �r� -���a� Phone: 7 l"
Tenant/Building Owner(if different): Phone: �j
Construction or Site Address: slot --- ,� :r'.� - ii / 0 1---r 27 ?f L
PIN or Parcel # from GIS:
S.ecific Directi.n to ob from Lillin.ton:
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Description of work to be done:C�� or dtJ r /02,C Job ost:� ( ��
Mechanical: New Unit With Ductw _ New Unit Without Ductwork _ Gas Piping _
Electrical: 200 Amp _ <200 Amp — Service Change _ Service Reconnect _ Other t�
Plumbing: Water /Sewer Tap __ Number of Baths __ Water Heater _
Permit Cost
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Permit Fee: $ /� l -- (calculated from fee schedule) I
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ /C ?. 6 0
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signatur7. �G. % 1 . 7 Date:/, 1/4
DO NOT SEND CAS r' LETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
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x r I p @ a , , PIN 9596-00-3969.
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9596 -01- 03958509115 .;__...
4459.0000001 SANDPIPER SANFORD15.0 SANDPIPER :DR
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SANDPIPER SANFOR25.0 SANDPIPER DC
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