SET UP •
r Application # �T SOO 5 7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number: 910 - 893 -7525 Fax 910 - 893 -2793 www.harnett.org/permits
Application for Manufactured Home Set -Up Permit
(Please fill out each part completely)
Part 1 –Owner Information:
Horne Owner Information (To be completed by owner of the manufactured home) T
Name: ROSPA( I,II io 4' Address:3250 ?Rader ade! Th.f li) AC/
City: t rt.J ; cl State: Ni. Zip: %%331 Daytime Phone: (PO) 658.-. 785 1
Landowner Information (To be completed by landowner, if different than above)
Name: Address:
City: State: Zip: Daytime Phone: ( )
Part 11 — Contractor Information (To be completed by Contractors or Homeowner, if applicable.
Name, address & phone must match information on license)
A. Set -Up Contractor Company Name: Rage` t. //7 t 71 s , Ov/(
PhonL:11 &58-'1 Address: 705D ( zoe" 17. Ga M
City: cf" t p;n State: NC.- Zip: 0331
Setup Signature: State Lic# 1/ • 11: /0
B. Electrical Contract Company Name: 45 d i / /,7 fir -
Phone: Address:
City: State: Zip:
Electrician's Signature: / , S%/ State Lic#
C. hanical Contractor Company Name:
-. ..
Phone: ddre •
City: State:
HVA State Lic#
D. Plumbing Contractor Company Name: // 9 /yf>6T .
Phone: Address:
City: _ St- Zip:
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Plumber's Si' nature: ,:s ! _��_� State Lic#
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Part 111– Manufactured Home Information
Model Year: j 9'7 1 Size: 44X Pi # of Bedrooms c�
Park Name: Lot Number:
I hereby certify that I have the authority to apply for this permit, that the application is correct including the contractor
information and signatures, and that the construction or installation will conform to the applicable manufactured home
set -up requirements, and the Harnett County Zoning Ordinance. I understand that if any item is incorrect or false
information has been provided that this permit could be revoked.
J _ / ! — o o
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Signature of Hoe wner or � gent Date
'Effective July 1, 2004, a County Tax Department Moving Permit must be provided before a Set Up Permit will be issued. It is
purchased from the tax office of the county that the home is moved from. If the home is from a dealer, we need proof of year on the
Form 500 and if available, the serial number.
List of inspections and Egress requirements available upon request.
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