TRADE 4
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Application #
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Remelt County Central Permitting �G vra rt ;
PO Box 65 Lillington NC 27548
910- 893 -7525 Fax 910 -893 -2793
www:hamett.org/permits
Certification f Work Performed By Owner /Contractor
dividual Tiro Application)
Owner (s) of Structure: � /�l,! W Y Phone:
Owner (s) Mailing Address: fo9if
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Land Owner Name (s): %44( Phone:
Construction or Site Address: 55-g tvt/
PIN or Parcel # from GIS:
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork New Unit Without. Ductwork Gas Piping
Electrical*: 200 Amp <200 Amp Service Change _ Service Reconnect _ Other
• For Progress Energy customers we need the premise number
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater 4
Specific Directions to Job from Lillinaton:
Subdivision: Lot #:
I 7 � ��r� rN will provide the ithe labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number Is /5 , which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code
and all other applicable State and local laws, ordinances and regulations.
Structure owner(s) signature: 7A A.4,/,0 c< C n.c.di\ Date: )/-/
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Com. Name:
Address:
County: Contr: « . : u «: ,: •
Contract. ': ' 'nature: Date:
• - mpany name, address, & phone must match Information on license.
TRADE 4/08