DOCUMENTS Application# 1 4 as
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 - Ph:910-893-7525 - Fx:910-893-2793 - www.harnett.org/permits
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner - of Structure: Phone:
Owner(s) -iling Address:
Land Owner Name(s): 'hone:
Construction or Site Address:
PIN# -arcel #
Job Cost: Descrip of Work to be done
Mechanical. ew Unit With Ductwork New Unit Without Ductwork Gas Pi. -• Other
-ctrical*: 200 Amp <200 Amp Service Change Service Reconnect Other
* For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap Number of Baths Water Heater
Specific Directions to Job from Lillington:
Cert6r-a4±(jr'
4-
Subdivision: Lot#:
I ,rad lea, will provide the //v, .— labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 1/3 C I a(do , 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.
( r ') I IIeDf 1 i (qv) 4000
Contractor's Company Name Telephone
PO 134 l0 7/ .t1vee M(1/3 .l( 838/f
Address Email Address
X30 act a
License#
1 • /
Structure Owner/Contractor Signature: 4/1_/.., moto _ Date: /CS 16 /7
By signing this application you affirm tha you have obtained permission from the above listed license holder to
purchase permits on their behalf. If doing the work as owner you understand that you cannot rent, lease or sell
the listed property for 12 months after completion of the listed work.
*Company name, address, & phone must match information on license