TRADE µ
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Application #
Harnett County Central Permitting " {;i
PO Box 65 Lillington, NC 27546 h ,_
910- 893 -7525 Fax 910 - 893 -2793
www.hamett.org/permits ° ' x
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Certification of Work Performed By Owner /Contractor - _e:1
(Individual Trade Application) , .
Owner (s) of Structure: gin.Ilh,ta 4- Tarr - 9- )renrlwell Phone: ' A 4Q7 0 1 -, 76 Yrz
Owner (s) Mailing Address: 1151 NI I\C - to / / -2 re) Ansier AC a. ?sj 1 l i,
Land Owner Name (s): Ince. Phone:
Construction or Site Address: 1 183% N WC H W d I A,n 'P (1C,7 S� 1 ''
: 1
PIN or Parcel # from GIS: o�i , 4, �,v 1 ,4 9-9 -/7_ - 07/ vob
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Job `Cost: Description of Work to be done / y 1
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Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping _ 3
Electrical': 200 Amps <200 Amp Service Change _ Service Reconnect _ Other
' For Pro ress nergy customers we need the premise number i
Plumbing: Water /Sewer Tap Number of Baths Water Heater
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Subdivision: Lot #:
I neov. 21M-tact provide the i~ te<Jlrr 4 \ labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is .5 , 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 and local laws, ordinances and regulations.
Q .DQ Structure owner(s) signature: ., Date: 7 - 7 - 1 b
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Company Name: )Zef fie Xlevh' icc. l Phone: 919 S5d b .4, I
Address: 80."1 I!e A nc ber V w .1 lo.) 'Svc , r1Qrs tnC i
County: vsJs Kt Contractor's License #: 51 L. 1
Contractor's Signature: Vc y C 4,09 Date: 1- 1 la
"Company name, address, & phone must match information on license. ,
TRADE 4/08 a
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LANDOWNER: ' I d // , - 1 -a • A
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MAILING ADDRESS: / d 3 rG 7 i A/
CITY:/ (/4 STATE: I / /lam ZIP:2 24"0/PHONE:
APPLICATION DATE: (Q ' • / (.../ APPLICATION # /9 CV 24 77o
APPLICANT: /VA 6( ) 9 6
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CITY: Y: �[ __ r STATE: Al C ZIP: (9-7 ael PHONE: (p 39 : `�
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PROPERTY LQCATIO : SR# K 2 /fI !I/ SR NAME: / 4/t ZIo /�/
PARCEL # (7 / 04 ii 0,9,1 PIN # OG fy —/Z — '9° 70. c a
ACREAGE: / (9 FARM NUMBER:
• it ATION OF li US P� BY TAX OFFICE: /
SIGNATURE / CEN ' . PERMITTING TECHNICIAN DATE
I (we) have read and understand the requirements to qualify for a farm exemption. I (we)
hereby claim such exemption because I (we) operate a bona fide farm which has a valid farm
serial number and is currently enroll d in Harnett County's Land Use Program. Within the
Land Use rogram I (we) participate in:
Agriculture ( ; Horticulture ( ); Forestry ( )
NOTE: Check each category that applies.
AFFIRMATION: I (we) the undersigned declare under penalties of law that the information
contained in this application has been examined by me (us) and to the best of my (our)
knowledge and belief is (are) true and correct. Additionally, I (we) fully understand that
falsification of information supplied by me (us) herein shall cause any permit issued relying
on such information, to be automatically revoked and a • ork shall immediately cease.
Signature(s) of Owner(s): Ara j .
Date: 7- 7- /
Date:
FOR OFFICE USE ONLY r
APPROVED BY:
/ Q Je DATE: (P " 1 ' I v PERMIT# / 572 24 776
DENIED BY: DATE:
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