SET UP 41-77+ P1
. r A pplication # /P ✓ g� C / Q 7
Harnett County Central Permitting ry4 a WK
Lillington, NC 27546 •: ' ?
Telephone Number: 910- 893.7525 ax 910 - 893 -2793 www.harnett.org /permits F � '
Application for �� factured Home Set -Up Permit , -z
(Please fill out each part completely) 3
Part I -Owner Information: :
Home Owner Information (To be completed by owner of the manufactured home) ,v {
Name: Lc s a ra lbV a Address: ""�(8ck X1 ( e Y` X411 ;
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City: .rP� State: N Zip: 7_'�3 7Z Daytime Phone: tiro Mt Z4 I `
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Landowner Information (To be completed by landowner, "i f d ifferent than above) 3' ,
Name: Address: ; : ,r
City: State: Zip: Daytime Phone: ( ) r ":91.-&, v
Prt I1 - Contractor Information (To be completed by Contractors or Homeowner, if applicable. ' ..; " . ' '
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Name, address, & phone must match information on license) -
A. .Set -Up Contractor Company Name: 1 r0 f/u 5 Y`n/ //PA- � (
Phone: 9/ - 3 0 $ f•94. Address: 6 7 6Q A Be / �, diC ` '� * �
City: r r : /1l,� / /C'. State: /VC Zip: s,�n 6, € ; p . 3 '`
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Setup Signature: , ,,,,_<,,, �u d State Lic# ?7741 ' fit w 4r Y
B. Electrical Contractor Company Name: '-+K!,` ,. •I• . ra .. i _I a ...a ,r, P ,
Phone: —qa-7 Address: Qq -_ di Otis
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City: -0 State L Zip: _ '
Electrician's Signature: A , , State Lic# + , � . .
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C. Mechanics on , me: w `t t1A
Phone: Addr: - t „} ,1;
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City: State: Zip: . ` ,"� .,
ion- ure: State Lic# °r `,, t,�µt '" ar-.
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D. Plumbing Contractor Company Name: S 0/44.7 r 6 7 - xv ' ' ;
Phone: Address: 4, "' 'b• :- „ •6 � a ;,
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City: � te: Zip: 5 �, '�
Plumber's Signature: t /f� y�e State Lic# ' f 41 � "i`", y
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Part III - Manufactured Home Information t. 4
9 4.] .40 7 t . P
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Model Year: I t 81 Size: is x Complete & follow zoning criteria sheet 1 , ° t nrtw
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Park Name: E0 i-e, I_ lkv1 h Lot Number: fi r ' l +t
I hereby certify that I have the authority to apply for this permi that the application is correct including t � Y r 4
information and signatur and that the construction or installation will conform to the applicable manufactur
set -up requirements' he Harnett County Zoning Ordinance. I understand that if any item is incorrect :;b }'1,'„s. 't
information has be: 1: . 1 •ed that this permit could be revoked. `' ' `en s t
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Signatu r: • 1 • , e • , ner or Agent Date r � k'
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'Effective July 1, 2004, a County Tax Department Moving Permit must be provided before a Set Up Permit will be isa , , ' , ..4
purchased from the tax office of the county that the home is moved from. if the home is from a dealer, we need P ° . ,r f t - ;h I
Pam; 500 and if available, the serial number.
List of inspections and Egress requirements available upon request Progress Energy customers must provide Pre 4. ,:.'11110 ` ° l
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