TRADES Yes nu Certification of Work Performed
-
/ 0 0
By Owner /Contractor
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1 /Y7-/-17:4 / Contractor Information / I, Lam-`` / will complete the fr`�/�4 - ` work on the project or
(Name) Tr de)
structure herein described. My state license number is0 All work shall comply with the
State Building Code and all other applicable St / & Local law, ordinances and regulations.
Company Name: 072L1
J // / / /7 � / �/ 725-5-..5 Mailing Address: /1 S S�/�!� /lT _c n` ��
Street Address: //5 : 574-//// 4- - S / - l f- /
C7/-
Business Phone: � 0 Email Address:l�<Je2 /-c. /e-c/
*Company name, address, & phone must match information on license.
Job Information
Land Owner's Name: 5" Phone: q��
Tenant/Building Owner(if different): Phone:
Construction or Site Address:'2 2 frn(L(..- k1i /vim
PIN or Parcel # from GIS:
S•ecifi Dir to Job from Lillin. ton:
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Description of work to be done: C � ICJ/ /TM Cost:-/ U
/ ?
k 0
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: $ / 6 (calculated from fee schedule)
Mail In Processing Fee: $3.00 nor appiicatIon
Total Enclosed: $ J () f ` a CI
Make check payable & Mail completed application form to: Hamett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: Date:
DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
GIS_Public: Powere By Freean 4.3.2 - TDC Group Inc. Pag 1 of 1
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