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Application # /
Mail In application
Please note if this application Hemet County Central Permitting
is part of a job in progress PO Box 65 Lillington, NC 27546
veldt open pemitts. 910 - 693-7525 Fax 910 -893 -2793
yes
www.hamettorg/permits
_ no
Certification of Work Performed by Owner/Contractor
(Individual Trade Application)
p �11, l 1 II'' - I Contractor Inform ation
Piaae H .111 �t�'m FCarhn 'win nc complete-the T J AC. work on the project or
(Name) I/�� / C r structure herein described. My state license number is V (471 r �
1 t l 0 . A11 work shall comply with the State Building
Code and all other applicable State & Local law, ordinances and regulations.
Company Name: k Lk- IiSi.a i FAir (!)r1( Ibn1n$
Mailing Addrt _ L
Street Address: Ln3 AfCISpf - Diann UJr)YY n(frOn 14E, 28405
Business Phone: - 313-1011 Email Address: NlWCIY1G &1 115gI ,i^k .
'Company name, address. 8 phone must match intermadon an license.
ob Information
• Land Owner's Name: PQALI &ur Phone:
Tenant/Building Owner (if different): JJ Phone:
Construction or Site Address: 1 I )Q Lv/Q, nQk! Pri L aa.�S i t a?7S�? 1
PIN or Parcel # from GIS:
Specific Directions to Job from Lillinaton:
Description of work to be done: Job Cost: /
Mechanical: New Unit Wrth"Ductwork New Unit Without Ductwork✓ Gas Piping
Electrical: 200 Amp — <200 Amp Service Change Service Reconnect _ Other
Plumbing: Water /Sewer Tap _ Number of Baths — Water Heater — J
Permit Cost �J}
Permit Fee: $ (calculated from fee schedule)
Mail In Processing Fee: $3.00 per lob For Electrical Permits with Progress Energy we
need the premise number provided.
Total Enclosed: $
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
fe
L illington, NC 27546 //
Contractor's Signature: � Date: ea llOL lD
"DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED"
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Individual Trade Mail In Application of 1 04/10
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