TRADES Application # 4 %5040 03
Mail In application
Please note if this application Harnett County Central Permitting
is part ofajob in progress PO Box 65 Lillington, NC 27546
with open permits. 910- 893 -7525 Fax 910 - 893 -2793
www. harnett. org /permits
yes V no
• Certification of WorKPerformed by Owner/Contractor
(Individual Trade Application)
L�� 1 Contractor Information
I, et t � re%0 ' will om lete t (/ Y \eGI 0...a.1 t a.1 work on the project or
(Na (ntCV1Aet1• � t�� (Trade)
structure herein described. My state license number is 14370 . All work shall comply with the State Building
Code and all other applicable State & L cal law, ordinances and reeggullat
Compan Name: Wf t/�i✓l WCJ Ert � ,`/ � q J ✓l ���� n �
Mailing Address: t O0 % c e✓\t ✓ t fir, ie /l1 t ✓l Nor t.(,tr . Ate. '2a3`i
Street Address: ( 00 €V\L.Mear; ErLMt,4 t4othL!oVot;otA,2a R
Business Phone: (9 oi gt 2 — 7 Email Address: A.
*Company name, address, & phone must match information on license. • SI, Y\2 . V
11 OVA $J b Information
oq
Land Owner'sName:l (( �� AI avvA GT v'1BI�A l A P hone(GI I 897 2354 -
Tenant/Building Owner (if different): P one:
M,d
Construction or Site Address: 101 ,nl \(./ s• • O U l LA,yyle • Ot S � Nj 22 7t2t
PIN or Parcel # from GIS: 070581 Ot 6ri GO •
S. e ific Dir- ctions to Jos from Li I'n•t•n:
.. .MIL .J�.� atrAAIST i o _ Mt/ s tAAA � i et o✓t o . 27 E. _
it . lirli',it lIPS7-- 17nAielEISPIRW H![7llr ! i - �, • •rox. • i7.
4 Sptit
Description of work to be done: C PA. ✓vNo Job Cost: . ) 200.
• Mechanical: New Unit With Ductwork New Unit Without Ductwork V'Gas Piping
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect Other
Plumbing: Water /Sewer Tap _ Number of Baths Water Heater
^n Permit Cost
Permit Fee: $ SO. 00 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per lob For Electrical Permits with Progress Energy we
MM need the premise number provided.
Total Enclosed: $ • CC0
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lill 2 NC 27546
•
Contractor's signatur: . I / -' ' • Date: 09/1071'0
* *DO NOT SEND CASH. INCOMPLETE APPL /CAT *NS WILL NOT BE PROCESSED **
Individual Trade Mail In Applicator: - 1 of 1 04/10
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