TRADE Application# / V 4 rO z 9,2
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910- 893 -2793
www.harnett.org /permits
Certification of Work Performed By Owner /Cdntractor
(Individual 1 Trade Application) /�
Owner (s) of Structure: NA/ cc&&nd l2chUC L1YPCy Phone: AD) 5 'o3 3
Owner (s) Mailing Address: 3i) S -Abet -H-r r J i
4n is 1 NC 2-750 /
Land Owner Name (s): Dctv(/ A. . Phone:(9 JO) ?ijr g0
Construction or Site Address: ;5 /SS Y( .
PIN or Parcel # from GIS: lint) 2. - — 2039
Job Cost: /2 9 Description of Work to be done �1'ICt let t- l>'(/� Ptl t�
XI ,S /a i 4/
Mechanical: New Unit With Ductwork New Unit Without Ductwork Gas Piping
Electrical *: 200 Amp <200 Amp x 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 L' 'n ton:
Htol NI --o `121 S on L SL(¢z CArr7Ln 1 V kitin �x- Garne>
N� " lhr br - niw.s -w - d � (sw 2. Qp on
N D olt. c)!-. -then be connis - latohcAk- 0..- 12d - ItSSIS -
Subdivision: `,f- tYY —TFAY ? 1 cL
r't!� tlfYl Lot 1 I
will provide the re ,-, f labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 4)=4$44-4 , 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 . nd Idcfil laws, ordinance ./and ray :tions.
Structure owner(s) signature: / -ea _ _ ; ` Date: 7 •
Company Name: /?, Phone: ctg- & ' / q.S
Address:7e 4- y SS c j County: _
Contractor's License #: � . -/ al Address:
Contractors Signatur :. � .,, Date
*Company ame, address, & phone must match information on license.
Individual Trade Application 1 of 1 06/10