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Harnett County Central Permitting 4 V.7-7S
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 -893 -2793
www.harnett.org/permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application) p�Q
Owner (s) of Structure: f0 F1&t.ClTyl� p Phone: 9 11 1 1– r ! " 0 p
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Owner (s) Mailing Address: C he r o e Be Land SGt.afor r , / (C4
Land Owner Name (s): Add r; / 5 - k c r. Phone: 4) 9g- 6431
Construction or Site Address: !° CN >tsj Sei IAA e.. .Sa.rFFordL ) C,
PIN or Parcel # from GIS: (oJ Semi.
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Job Cost: 110- Description of Work to be done 441 ca l ti ,✓P, T � fe- d e_
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping _
Electrical *: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect ther
' For Progress Energy customers we need the premise number
Plumbing: Water /Sewer Tap _ Number of Baths Water Heater
Specific Directions to Job from Lillington:
Subdivision: �( ` ' Lot #:
I `flOrn►p, , )O t_ ' will provide the CikGCri labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is , 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 . • •cal laws, o •' an -s and regulations. /
Structure owner(s) signatur=s. ,...__ /' / Date: �P4O/� d
Company Name: ' t Cam/ - 4 ' _ / C Phone: 9/9- S'4'a7
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Address: •O r /- . • �, - i 0 � r County: lie.
Contractor's License • • t. // - : Email Address:
Contractor's Signature: -.li► f if ■ Date: 600 f ie
*Company name, address, 8 phone must match information on license.
Individual Trade Application 1 of 1 06/10
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