TRADE Jul 1b Cu1u 1u: 1:7nn nr LnaCRJC l rnn r+..
Applications J P O 2 4 YC
Harnett County Central Permitting 1Q )
PO Box 65 Lillington, NC 27546 (z /D c
910 -893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application)
Owner (s) of Structure: 0 O{}/ fytsve.es LLC- Phone: f(? t fl —fsi6
Owner (s) Mailing Address: Pa 11)K t 11
AILAIL NG put
Land Owner Name (s): 4n , p1TU o cc A -k a, N P oh ne: fir If 7 -tQ
Construction or Site Address: 470 Pv.tif C,- ---
PIN or Parcel # from GIS:
Job Cost: Description of Work to be done - ,r(i L(,r
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping _
Electrical*: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect Other
• For Progress Energy customer' we need the premise number
Plumbing: Water /Sewer Tap ` Number of Bathe _ Water Heater
.... 1 e1 _•r .1: • •• 1111 1! •a:
/tffi'e • T O(` 1-W.4 c ' r. i L . a . 4._
;1!' .. !f:' "�� CI
Subdivision: a (fie -*te jhr�.i I Lot #: I TT
k' eh'9- (r'j zL— will provide the cbcc r! c f labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is (0 gag- (L , 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 1 laws, ordinances and regulations.
Structure owner(s) signature: n r / / . Date: loll-0
R .42:s 4- 5";t1/45 gie -inn,
Company Name: �r r Phone: 9(k' (I( - ? 7( 0
Address: f ,;Ztit LJ1l"Zs& 1 6r. 4-tittic 7 ICS 1 County: 4 k (c.c-
Coniractor's License #: L. gO Q- 6& - Email Address:
Contractor's Signature: `
� dhak O1.rlat6k Date: "1(15/10
*Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 06M