SET UP frC
Application # 1 `J • . ° Z .__> 7
\ , > 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 Horne 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)
Name:yalis A,..d IIvtr)tss Ow Address: 3L1'/ 00 : cAuisn't R
City: State: g L Zip: Y b Daytime Phone: (qty) 7 70 -4 /a 7
Landowner Information (To be completed by landowner, if different than above)
Name: Address: .
City: State: Zip: Daytime Phone: ( ) • .
Part II — Contractor Information (To be completed by Contractors or Homeowner, if applicable.
Name, address, & phone ugt match information on license)
A. Set -Up Contractor Company Name: A5 4 i 'v' .
Phone: Address:
City: . r Zip:
Setup Signature: � / State Lic#
B. Electrical Contractor Company Name: orc a. KA. ta-r
Phone: 914 -7 SG 99 Address: `f 3/ 4 //r* /N„/t 1 S.
City: 21.n. ./ _Yl Ar me State: C,, .r zip: 4-75 % �--. i
Electrician's { Signature: .'a..e &4 t• / 5
_ � A • lw State Lic# / l 7 5 -k °
i -r '
- - C.` ' "Mechanii Contractor Company Name A i< • d 1 A/9 . eiec ee s L.GL
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Phone: / /g• .3 3 7 (0 / /2—Address: PO f c Pc /o L -
• City: ,.. C r State: • Zip: ,,?733/ �.
HVAC Signature: a : '" State Lic# ai` q n 4 g Z 20
D. Plumbing Contractor Compa y Name: I fu /' 5 / "P/ /' �]S ofd > "/,
Phone: Address:
City: , State: ' Zip:
Plumber's Signature: a . i f G� State Lic#
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Part III — Manufactured Home Information
Model Year: 194 Size: AT X 5 °t # of Bedrooms -
Park Name: Lot Number: 9
I hereby certify that I have the authority to apply for this permit, that the application is correct including the contractor '
information and signatures, and that the construction or installation will conform to the applicable manufactured home
set -up requirements, and th Harnett County Zoning Ordinance. I understand that if any item is incorrect or false ' ''�
info, .n - . beep prov tha t s permit could be revoked. 1�
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i of Home Owner r ent Date
'Effective July 1, 2004, a County Tax Departm nt Moving Permi( 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.
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