SET UP •
Application # 1/ ,s 2 4-z/2 Z
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
' • Telephone Number: 910- 893 -7525 Fax 910- 893 -2793 www,harnett.org /permits
Application for Manufactured Home Set -Up Permit
(Please fill out each part completely)
Part I -Owner Information:
Home Owner Information (To be completed by owner of the manufactured home j
Name:
CIGCex1Ce. Lce ■ 0,..\ Address: a 1 � 5 '\--\ st n L t
2 /J G( -
City: 1) Lk. 11 ' h State: NC Zipd 33 Daytime Phone: ' ) o - 1 - �� Z 2 .
Landowner Information (To be completed by landowner, if different than above)
Name: (31-'C' Address:
City: State: Zip: Daytime Phone: ( )
Part 11 — Contractor Information (To be completed by Contractors or Homeowner, if applicable.
Name, address ,& phone must match information on license)
A. Set -Up Contractor Cogpan� � Ad Name: i � ceit'G - .- 4 S hi A '(VSO `K C S
Phone: - 10-9g 1 - `4' 1 dress:7 1 0 l A- Ii
Co ^r tr.-
City: U, / s .t:: rip: .-,2 33 q
Setup Signature: �a r .a . re _ State Lic #DOr /dot
B. Electrical Contractor Company Name: CI enfmS ��CJ`V C e � 17
Phone H- 991 -•gq. Address: C&'3 co, p-CIC er'lnl &
Cit ' 6 e t dP State: Ai C_.- Zip: r l Cr, O
Electrician's Signature:, 4-- State Lic# I >5 1 D L
C. Mechanical 11/19
l Contractor Company Name: C ( 01 ) s S� ( e v o
Phonh.'1 1 - aL( 1 Address: (UQC ) yco -QiC N._v\i\ L •
Cit ii. `e' t State: y( C Zip: - C> 3
HVAC Signature: , /._., state Lic # I Z 3-2- (lid-,
`1
D. Plumbing Contractor Company Name: 4� c' &> C t+ `., u.x \ i r e cf-,
Phone f- (4<Z- -qSS Address: 7 .. ( o r • •
City: N V■S ;, \\ us.._ 6 ,1 � fate: [�n�� ",(�/C / a - Zip: 5 -2.___ Plumber's Signature: {, yJ �jt J{"! Le ,t4 State Lic# ` O
G S D F
Part III - Manufactured Home Information
(/ (JU
Model Year: C \ SizerD 0 X44 Complete & follow zoning criteria sheet
Park Name: Lot Number:
I hereby certify that I have the authority to apply for this permit, that the application is correct including the contractor
information and signatures, an.'th. the construction or installation will conform to the applicable manufactured home
set -up requirements, and th- H.,/ ett County Zoning Ordinance. I understand that if any item is incorrect or false
infor�%.s be- , . /'at this permit could berevoked.
/ /ii /7 4 _i L 0
^M ature of me Owner or Agent ate
*Effecti e July 1, 2004, a County Tax Department Movino Permit must be provided before a Set Up Permit will be issued. It is
purchased from the tax office of the county that the home is moved from. If the home is from a dealer, we need proof of year on the
Form 500 and if available, the serial number.
List of inspections and Egress requirements available upon request. Progress Energy customers must provide Premise Number.
SETUP 4108