TRADE Application # /! ._TDB' . R. %e? a
Harnett County Central Permitting t/
PO Box 65 Lillington, NC 27546
910 -893 -7525 Fax 910- 893 -2793
www.harnettorg/permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application)
Owner (s) of Structure: Pm women CLL/s Phone:
Owner (s) Mailing Address: el 7 3 bp.o2.12. RD
/. /LL/NG 7nr Z'74
Land Owner Name (s): Phone:
Construction or Site Address:
PIN or Parcel # from GIS:
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork X Gas Piping _
Electrical': 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 Lillinaton:
Subdivision: Lot #:
I fCOiw -c-o 2Wtt nPso,J 1 will provide the HV4O labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 22 SSCI , 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 ands, ordinances and regulations.
Structure owner(s) signature: CJ` -fr- Date: 3 c A -144 "3 0
Company Name: CHaocav+a s C°NZ4ou /M Phone: 9/0 442 - 7!.
Address: 162 -2 VAN 03,.,. z-A, Ave FHYrrsav/r.4E N. C-
County: L Contractor's License #: 2 2 SS O
Contractor's Signature: Date: 3d had- /0
'Company name, address, & phone must match information on license.
TRADE
4/08