TRADE -ELECTRICAL Application # ��. c
Mail In tration a 9.51129 �
Please note if this application Harnett County Central Permitting
is part of a job in progress PO Box 65 Lillington, NC 27546
with open permits.
Telephone Number 910- 893 -7525 Fax 910 - 893 -2793
yes no www.harnettorg
Certification of Work Performed
By Owner /Contractor
Contractor Information
I, c1/4.A-..--,7 will complete the --/-11/4-C 6 t )work on the project or
(Name) (Trade)
structure herein described. My state license number is �004 `F - c . All work shall comply with the
- State Building Code and all other - applicable State & Local law, ordinances and regulations. -
Company Name: - 371.,2 or-i-( L. 64 -
Mailing Address: . LC ( a c i 4 c if() 5e
Street Address:
Business Phone: (7 (9_ 2 '[ -S /5 / Email Address:
`Company name, address, & phone must match information on license.
Job Information c�
Land Owner's Name: - 8� �o-�ro Phone: /�0 X - D
Tenant/Building Owner(if different): Phone:
Construction or Site Address: 5 � , _, Y]1� r �� -- / - nC tan L-0
PIN or Parcel # from GIS: —
S•ecific Directions to Job from Lillin•ton:
gyp. - • �(j
Description of work to be done: -CLWes` `--� Job Cost: 1 5 - (
Me New Unit With Ductwork New Unit Without Ductwork Gas Piping
Electrical: 200 Amp ✓ <200 Amp Service Change _ Service Reconnect _ Other -
Plumbing: Water /Sewer Tap _ Number of Baths _ Water Heater _ ,
tab-a - 11VA -
c `� l� Permit Cost
Permit Fee: $ S i` V� (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ 3 (/ v)
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: ( -dam Date: /�-
DO NOT SEND CASH. INCOMPL E APPLICATIONS WILL NOT BE PROCESSED.
10/06