Untitled Fax Server EDT 10/21/2010 9:14:14 AM PAGE 2/003 Fax Server
Oct 20 10 10:49a Sonya Wiltaord s 1 - 000 - aoit t to p. 1 /
Appifotion # 1 ✓ ✓ 2J , 2 7
,1.t ,� Harnett County Central Permitting
\ ���J1 PO Box 65 Ulinyton, NC 27548
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• Telephone Number: 910 - 893.7525 Fax 910- 893•27A3 www.harnett.org/permits
J O ASSUcafion for Manufactured Horne Sel -Uo Permit
(Please fill out each par! completely)
Part I -Owner Information:
Home Owner Information (T be completed by ner at the marxlffecture
Name:1i1 1,1-0 i0 kti W I i tk dress: tee 1 1 `.•"7 '414(\) L '"+
City:1 a \ l t 1 State: NO , zip: 3194 (Daytime Pitoner•7 i t 4 !
Landowner Information (To be completed by Landowner, if different than above)
Name: '71(4 , Address:
City: State: Zip: Daytime Phone: ( )
Part It — Contractor Information go be can plated by Contractors or Homeowner, if apprieable.
Name, address. 8 o .: must ma h in ',nation on license)
A. Set-Up Contractor Company Name:
P % /
Phone: - ;� Y • ;dress. . _ . , . ; /: ,
• . K� 7� .
City; � , Sta1O: fit° Zip: ,4 7 ✓
Setup Signature_ s 4? i _S tate Licit o�g, , •
B. Electrical Contractor Company Name: i f 7 F-4. 1 A e t o l- t t
6Q'Cf'^77DI Phone. 5 - P 41 2 e 5. . Address: v /f P,yNc6xeIrif , '` ,�1 y,,•.
City: - ' r & �P� : t� L , . State: /11 c-- ?Q: _2 '7 4-9J �t .,:,, re; Electrician's C?ir 11 ✓ State Lic# 3 7 4 R-1--
C. M het et Co n nt tr r j acto � r yCom y Name t •t.Qflr. A. _U c . C cfrie-S
P 1 / 1 / / - 9 Address 1X T t \..G \t. ` % e f ie Ls (_.0 n e. l `
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City:. QA/ State: _ - -= :;:5.a1.'�lip c31r O
' ` r I / _ _Sta i�c# `s
HVAC Sienetu. e: u. ni{� (7 d �
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D. Plumbing CantraMorGOCr:pany _ t Le - 1 0-4 (4 A 1 ?1W' 1.71. 1 f'..
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Phone: 6747 - 3 i r7 Address: /U b/t L1/ -;.�,s, ,
City: ili1 5r•1 I" State: C Tip: j.. G .. ?
Plumber's Signature! 4 State Licii s r i
Part 11I — Manufacturtad Home tnformailom i
�n r,
Model Year /' 1 ',7 Size: t'I X 7P Complete a follow zenMg critevie sleet " ".
Park Name: // (Yli -kP Lot Number. 4" J r
I hereby certify that I have the authority to apply fa this permit, that the application is correct inctudino the `'I. ';'y':;'; : -
information and signatures, g�`ar lion or installation will conform to the applicable manufaCni i i r
se regri , et4s. andt et oun Zaftig Ordinance. I understand that if any item Is Inc t
naroWdg� at t permagnouN be reeked. $ a � '� •
hT tG
� -- - re of ner 0 eats Date
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'Effective Jufy 1.2004 a county Tier Department Movhro Permit muse be prevlded before a Set Up Permit wffl be I r^ r ,
Purchased from the fax office of the carry that the home Is moved from. If Yee home is /rem a dealer, vie need P „. 1, , „c,.
Fort 500 and if available, the serial number. .
Listot inspections end Egress requirements available upon request. Progress Energy arstomers must provide ' t r . '(
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