BUILDING Application # la 00 2 5 r n
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Certification of Work Performed By Owner /Contractor
(Indivi . al Trade Applicatio )
/
Owner (s) of Structure: 1 , � / / .�.r / Phone:
Owner (s) Mailing Address: 22 A ; f /
Land Owner Name (s): Phone:
Construction or Site Address:
PIN or Parcel # from GIS: D
Job Cost: Description of Work to be done 61,11 1 r Al
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
Specific Directions to Job from Lillington:
Subdivision: //11'' nn Lot #:
I 54 A P /twill provide the /11 labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is 4 S 4 I/ //11/* , 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 c laws, ordinances an regulations. L i t O r Structure owner(s) signature: i Oy 2 4 Date: i) 76
Compan Na me: / Phone: _
Address:
Contractor's License #: Eu
Contractor's Signature: _-I •.te:
*Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 06110