TRADE • Application # i‘ 6 °
Mail In application
Please note if this application
is part of a job in progress Harnett County Central Permitting
with open permits. PO Box 65 Lillington, NC 27546
Telephone Number 910 - 893 -7525 Fax 910 - 893 -2793
yes no www.harnett.org
Certification of Work Performed
By Owner /Contractor
Contractor Information
I, �y Cw-�� u•�A ,_ will complete the +F V L work on the project or
(Name) (Trade)
structure herein described. My state license number is 4,-2- 51 . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: € -_-1 ( (A-
Mailing Address: S C( Ac(o 4 4 t-+.- - ( 01 '7 S a S�
Street Address: 5 - n
Business Phone: q � R l S ) Email Address:
'Company name, address, & phone must match information on license.
Job Information
Land Owner's Name: 0 LI or Phone:g11) 3 r7 9 S
Tenant/Building Owner(if different): Phone: M
Construction or Site Address:_ 3 A (( C� -B a r � �l.t - t-_- -y 'l C.i_d733 Sc3
PIN or Parcel # from GIS:
Specific Directions to Job from Lillington:
v0
Lillington: r
-Fa 9 "5 n " 4.6,,C � :p2-S _
/ �,l
Description of work to be done: \ i c_.._2-- -Y P ob Cost: V 5:2 9 S U')
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork ✓Gas Pipirt j
Electrical: 200 Amp _ <200 Amp _ Service Change _ Service Reconnect _ Other
Plumbing: Water /Sewer Tap _ Number of Baths _ Water Heater
Permit Cost
Permit Fee: $ (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ 5 - 6
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: Date: / -4 4 -I
DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
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