TRADE /, a
Application # /9 5 2 `1
Harnett County Central Permitting - 4
PO Box 65 LillIngton, NC 27548 a,
910- 893 -7525 Fax 910- 893 -2793
www.hamett.org/permita , .
Certification of Work Performed By Owner /Contractor
(individual Trade Application)
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Owner (s) of Structure: 1 U I k Phone: ' /c i 10-6)-07 t
Owner (s) Mailing Address:
()'() PO 6s3
r524l - lined-- IA) c- 2-')33( q
Land Owner Name (s): Phone: !
Construction or Site Address: ISO 1 M1) I vnf l Ch Gvweyon L
PIN or Parcel # from GIS: ge-l/„ - 30 - oyd, 9 P 0 ,/ 0 7f qy 7 4/ 0019 2
Job Cost: Description of Work to be done 2 �0 /4 El A-- /�05 L, t r/ 4
Mechanical
New Unit With Ductwork _ New Unit Without Ductwork Gas Piping _ 1
` /
Electrical': 200 Amp K<200 <200 Amp Servk:e Change _ Service Reconnect _ Other _
For Progress nergy customers we need the premise number
Plumbing: Water /Sewer Tap _ Number of Baths _ Water Heater
5.-A' D :.Ki• • •• 1•11 1!I•1:
M;1' i - -J-vvn k __ -- -, - --
.'fn; l Gill u u 6-4c i. • : = s
Subdivision: L o #:
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I _ A� !i y �/n 6 !�- will provide the / f / labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is /A y g /!/r c , which entities 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 U Date: lb -- 0 1 ,0 - ') 6
,
Cm.:�. -.. -: Phone:
_(
Address:
County: �t
Contractor's S 1 : _ r Da e.
ri me, address, a phone must match Information on license.
TRADE 4/08