TRADES VD/ LL/ LULU VD; JU J1J I (ODUODU PIHI,I'.J rICH 11IYV rHOG ULI UL
Application # //i (2 72
Mall nt application
Please note iftbis application
Harnett County Central Permitting 012 �f 4
is part of a job in progress PO Box 65 Lillington, NC 27546
with open introits. 910-893-7525 Fax 910 -893 -2793
www, h amett. org/pe units
yes no
Certification of Wont Performed by Owner /Contractor
(Individual Trade Application)
,r�
Contractor Intormation
I, A & i? ) sit . will complete the /( work on the project or
(Ns r (Trade)
structure herein described. My state license number is _2f'7F7 . All work shall comply with the State Building
Code and all other applicable State & Local law, ordinances and regulations.
Company Name: fr 5 ie ' �f p-,4r Cv • , -lien i C
Mailing Address: C Da f ✓ S4 nav -ol.. 4'C 1
!! g,y9.r 77 ? !l
Street Address: last el P
Z
Business Phone: 19 `7 7 H -f 4 7Y a Email Address:
*Company name, address, & pnoae must match Information on license.
_ �` � rr// � ,fob Intonnabin �
Land Owners Name: / f t- / ,t/ ` QJk ( Phone: I f 0478 - LS - 1 ,
Tenant/Building Owner (if different)'• Phone:
Construction or Site Address: 21 fl l d *-a trc S' 42,, Cot
PIN or Parcel # from G15:
i J m Lillt t, 4
on
(-i w 27 M -i-, � Y <F7 .�_ -„ 3 ;/ 4/... / 4 /ji, f r pit
Description of work to be done: /106;-C w 0 •112:10er its. 3 'i rick v 09 /Job Costl`! M
Mechanical: New Unit With Ductwork New Unit Without Ductwork ' Piping
Electrical: 200 Amp _ <200 Amp ,^ Service Change _ Service Reconnect r Other
Plumbing: Water /Sewer Tap Number of Baths Water Heater
Permit Coat
Penult Fee: $ -Co. 00 (calculated from fee schedule)
Mail In Processing Fee: 53.00 per iob For Electrical Permits with Progress Energy we
need the premise number provided.
Total Enclosed: $ 53 • & Z ,
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractors Signature: Date: VI ‘ v -- / O
*'DO NOT SEND CASH. INC th TE APPLICATIONS WILL NOT BE PROCESSED**
Individual rode Man In Appli,SVon 1 or 1 04,10
UD/ LL/ anti UJ[ 3U JSJ I / DUUDUU 1•INLnJ naN i ,LINU 1 eltw
Application #
Mail In application
Please note if this application Hamett County Central Permitting
is part of a job in progress PO Box 65 Lillington, NC 27546
with open permits. 910693 - 7525 Fax 910 - 693 - 2793
www, harnett.org/pemnits
_ yes no
Certification of Work Performed by Owner /Contractor
(Individual Trade Application)
Contractor Information
,, kk � t r et/ will complete the e / � G J •''c 4 1' work on the project or
(Name) (Trade)
structure herein described. My state license number is A 45.1 v . All work shall comply with the State Building
Code and all other applicable State & Local law, ordinances and regulations.
Company Name: 2' / ('4 bete, fie t
Mailing Address: )/ -. 3 - 4_c 4.„ S < > L
Street Address: / I Z n t s a h S )Lr e e 1 r
Business Phone: 3 6 - 3 - / / Email Addressn4 C t f t C 7� et
'Company name, address, & phone must match fntormaaon on license. ^ `;
M .// Job Information 9
Land Owner's Name: nem /' l e NP* ( Phone:6 y / ` fr? #lit
Tenant/Building Owner (if different): ® Phone:
a !sr or Site Address: r Pen2o.rn 5 SS. 4 /t'
PIN or Parcel # from GIS:
Aaecific Directions to Job from Lilinaton:
Description of work to be done: Ke C - 74 Os ides: SW4( u ., ,`+ Job Cost: c ifie 10 0 , eyrl
Mechanical: New Unit With 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
Permit Cost
Permit Fee: $ .Sar 00 (calculated from fee schedule)
Mail In Processing Fee: 13.00 per lob For Electrical Permits with Progress Energy we
need the premise number provided.
Total Enclosed: $ - ?' 0 0
Make check payable & Mail completed application font to: Harnett County Central Permitting (HCCP)
PO Box 6S
• �� �" Lillington, NC 27546
Contractor's Signature:(G,�i�- L �° Date: /
**DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED**
individual Trade Rig;: In /ApplKAtion 1 of', 04 "I O
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