TRADE Application* / / t ' O g �ly�
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 /Contractor
(Individual Trade Application)
Owner (s) of Structure: Kipling Methodist Church Phone: 919 -868 -8187
Owner (s) Mailing Address: 55 Kipling Church Road
Kipling, NC
Land Owner Name (s):
Kipling Methodist Chur Phone:
Construction or Site Address: 4/(‘
PIN or Parcel # from GIS:,lj O/' 57 '
Job Cost: $2400 Description of Work to be done Move service entrance cable, add new disconnect
for service entrance cable.
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ 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 Lillington:
401 N. To Kipling Methodist Church on right.
Subdivision: Lot #:
Richard Beasley will provide the Electrical labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 25('W,39'L— , 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: Date:
Company Name: RPB Electrical /p� PI/ 9/9 J ��
Address: 2(92- LE2/1NiC Sin/ Ty 4/1 PI/ County: 7/44- /2A/e71
Contractor's License #: 2 f(-3g — t— Email Address:
Contractor's Signature: • ,_fara.e Date.
'Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 06/10