TRADE se AO 41:Gt1 Yg:
Application 0 /7 .) c
Harnett County Central Permitting
PO Box 85 Liill gton, NC 27548
9108934525 Fax 910 -893 -2793
worn, hamett. orplpermits
Certification of Work Performed By Owner/Contrector
(IndMdual Trade Application)
Owner (a) of structure: 1 3 o;cl R% 1G/ S}� n ,_dims: al-1•7 -
armor (a) Mailing Address: 5 ti FA. ("I .$) hs c, -
and Ownet Name (3): Nut ti P t Usk y 15 km .,...; -. Phone: 347- S8 , �5
Consrnrction or 5fte Address:
PIN or parcel a from GIS:
Job cast:' sL _oeacriprion of work to be done rS
_pot: K Li to ‘0c
S,
Mechanical: New Unit With Ductwork New Unit Without Ductwork _ On Piping
PlectrireM: 200 Amp, '200 Amp _ • Service Change Santee Reconnect Olhvr
• For Progr s. Energy arlomers va rasa the pmnte number
Plumbing: Water/SewerTap Number of Bathe Water Heater
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Mtn-. • -- •) ew 1 1 -. t .'I.1 Aw•.t al • j s m to M 'is-+ ti. CcdnwF 1 €/
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eubdivieion: - , Lot t
I in, , Ct. Dc.., will provide the 5sj`t ∎. s Door on this structure
(Cantrectors Ns me) ' (Trade)
lam the building owner or my NC state scene number Is 'a) n 4 /.y , which .r me to
perform such work on dw Moss structure legally. All work shell comply with the Stab Building Code
' end 9l1 otner upplloeble State and local laws, ordinances and regulet$ons.
Structure owners) signature: Date:
Company Name: 1 fir r)1 A - - i`>Afr(y _ Phone: R`f 4 . •.3t <2l(
Address: ifs -U Y 31 7 _ Count , / ✓Iw 5 t‘ •r
Contractor's License a; epic." . mail Address: Mt. d 31 3 ( Act
Contractor's signature:
`Company non, address, & phone must match Information on Sane.
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