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Application # /2 OG 2 <7 7 n i
Harnett County Central Permitting r.":
PO Box 65 Lillington, NC 27546 . n Fk.
910-893-7525 Fax 910- 893 -2793 4., r , +
www.hamett.org/permits
Certification of Work Performed By Owner/Contractor
(Individual Trade Appli . tion) :u.
Owner (s) of Structure: • 1 fell r
t l Phone: 2t 9�0 - ga-ea "
4
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I r Owner (s) Mailing Address: 1 r - �imvz�I /� �. •
0 Air. 0h t d1/
Land Owner Name (s): Phone: " ::
Construction or Site Address:
PIN or Parcel # from GIS: , 6471 , a) 97 02 °f r p /, - - f777
Job 'Cost: Description of Work to be done /4," 4,,,,,,,
5
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork Gas Piping
Electrical': 200 Amp _ <200 Amp Service Change _ Service Reconnect _ Other _
. For Progress Energy c sto ere we need the premise number
Plumbing: Water /Sewer Tap Number of Baths Water Heater
Specific Directions to Job from Lillinaton:
Subdivision: Lot #:
I pp
it will provide the /-f labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is /y 8/,4 O , 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.
Structure owner(s) signature: i. _ / is, 1 SKI I Date: /J — So el()
,
Company Name: Phone:
Address:
County: G ontra or ert •
Contractor's Signatur • Date:
*Comps me, address, & phone must match information on license.
TRADE 4/OS