TRADES Application # r0 577 0
Please note if this application Mail In application � - � e re
is part ofajob in progress Harnett County Central Permitting
With open'pennits. 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
I Contractor Information
I, d 0 i,'N"� "'w will complete the work on the project or
( ame) (Trade)
structure herein described. My state license number is 5 ` . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: r- S. 4 J W 9
Mailing Address: `-L`€ - 0 1 'Tzar G L - -7 r -
Street Address:
Business Phone: q 1 3 `Z kt--. 5 / 5 I Email Address:
*Company name, address, & phone must match information on license.
Job Infor ation
Land Owner's Name: ` � -f; 0 (.. /J Phone: 9(0- 4 ?"")- 3 0 I
Tenant/Building Owner(if different): - ' n Phone:
Construction or Site Address: 2-1; I ^�" (`5 / C
PIN or Parcel # from GIS: 3 9 0
S •eoific Directions to Job om Lillingtoni - in, Kw -,
� t7 � � `
4a _ crzin 1l e. - ' % I�
U �+-�__ rI e Job cost: �I d Ij
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
_ _
Plumbing: Water /Sewer Tap _ Number of Baths Water Heater ____
Permit Cost
• Permit Fee: $ 5 ft U' (calculated from fee schedule)
Mail In Processing Fee: $3.00 oer application
Total Enclosed: $
Harnett
Make check payable & Mail completed application form to: PO Box 65 unty Central Permitting (HCCP)
Lillington, NC 27546 74
•
Date: art
Contractor's Signature:
DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. toros
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