BUILDING Application* lV v b O 2 S� �p
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793
www.harnettorg/permits
Certification of Work Performed By Owner /Contractor
/
(Individual Trade Application) , / M ecnr �
Owner (s) of Structure: 1- r & # 0h0 3 c r e M td PNo /Ms
910 293 -.2 yoZ
Owner (s) Mailing Address: /CXJC) d: e f cv4.5 ,e. 4
ki a.nc Jc ,s2 5
Land Owner Name (s): (A Y$9 -trn) Me c � we: /
Construction or Site Address: ! v ��! ` S c_ •� ,!„ /cc Af
PIN orrP",arcel # from GIS: (')5 /y- o� -yy4 ea 9 er
Job Cos (]r Description of Work to be done •
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping _
COO 200 Amp _ <200 Amp _ Service Change Service Reconnect _ Other /_ -UA M PI IA
For Progress Energy customers we need the premise number c#
•
Plumbing: Water /Sewer Tap _ Number of Baths Water Heater
pecific Directions to Job from Lillington:
/2 S y .PS1 /,c� / -7/4 X4 no 4/ fi it
Subdivision: Lot #:
i/ 7X / //4 EA./ will provide the F2 labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is h€9 , 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: / Date:
Company Name: /%'7R /C4 (/f�C c�.r //C Phone:TV <WV
Address: /.z 17 mot./ A' e/. c' •c7J12 2.. County:
Contractor's License #: 4/9 /1 v mail Address:
Contractor's Signature: � Date: /4- l/
*Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 0611