TRADES Jun 24 10 06:49p kelly douglas (919)499-6900 p•1
JUN.25.2C1f 15:13 .,..
•
Appilcallan • /d ‘ - - - r 0 1 : 0 4 - 1 7 / 6 / 1 7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910.893 -7525 Fax 910- 893 -2
www. harnetl. org /permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application) p c7 q p / q
Owner (s) Mailing Address:
� 1 Phone: / `! `' 7 / (, 2.3 U
Owner (s) of Structure. L -a L
6 C C a gS4� 6-
�M L 2d'✓✓
Phone:
Land Owner Name (s):
Construction or Site Address:
PIN or Parcel # from GIS: •
? p �I � t �c O 5i c� RA� e
Job Cost: 1 7 as n -es°ri lion of cork A °ne T 4 • cYT L C. r 3
w
Mecharicsl: New Unit With.Ductwork, New Unit Without Ductwork , Gas Piping _
Electrical': 200 Amp ✓ <200 Amp Service Change Service Reconnect
• For Progress Energy customers we need the premise number
Plumbing. Water /Sewer Tap of Baths _ Water Heeler
S., -cific Di, i•n • J•• fro 'll'n•t• . b 4 $a V f L. LE
a. r { � 5n1run16+,1" Pii1/LM)
Subdivision: Lot #:
labor on this structure.
I will provide the (Trade)
(Contractors Nara) which entitles me to
I am the building owner or my NC state license number is , with the yv w tare en Code
perform such work on the above structure legally. Ail work shall comply .
and all other applicable State and local laws, ordinances and regulations.
Date: --
Structure owners) signature:
/ Company Name: ��, Phone: � rJ l
jam/ -
y rVC . nry:
� o s L cri� C n S un Le
./ Address: mail- - 1- 6515 - ::ri /' Sr r'ce.. --. /vet—
- ( � Ema Address.
✓Contractor's License*: < � —;---c)--"/0
r � � Oate:
/Contractor's Signature.
*Company name, address, & phone must match information on license.
9e!10
Ind'vid l rode ApCrirallon
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