CHANGE OF CONT Application tt L40/67
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546 - Ph:910-893-7525 - Fs:910-893-2793 - wwwharnett.org/permits
Certification of Work Performed By Owner/Contractor
(In du Trade lication) O ?lei--
Owner(s) of Structure- (( Phone: 9/I to�,?l-//�o�J
Owner(s) Mailing ress: 2-sr& To/ /7r .S7/G /Or
/ Gr�7�dl.r-o 0r it/c 2-2(12-
Land
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Land Owner Name(s): 4444/A (.: tcLc </S/rba , 1NC, Phone: 9// #e 226—
Construction or Site Addre s: Z2 &s.Cdf,Gt/ 0r.
PIN N osos-87- 7W).. Oa 0 Parcel# oguards- 0422�01/- 2
Job Cost(Required)/.-k- Description of Work to be done Neel L6.L/37/7fCir?).1
Mechanical: New Unit WithitDuctwork_ New Unit Without Ductwork_ Gas Piping_Other_
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 Lillinoton:
Subdivision: /// A9t504( &ek e/K4 //i y _ Lot It: /08 3
I 8444@eo-�L-'G will provide the Glea//riled labor on this structure. •
(Contractors Name) (Trade)
I am the building owner or my NC state license number is ,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.
O4.Ford. idearrel LG 6- 9'o 3Z3- 409.3
Contractor's Copsggany Name Telephone
f' rt /S.- Dr Ate Allo NC 2,8.3S'8 bArdele<ariaa ,u:i.Co04-
Address / Email Address
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License# /
Structure Owner/Contractor Signature 1 (y Date: T -2 -/?
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By signing this application you affir you have obtained permission from the above listed license holder to
purchase permits on their behalf. It doing the work as owner you understand that you cannot rent, lease or sell
the listed property for 12 months after completion of the listed work.
`Company name, address, & phone must match information on license
Faxed or Mailed application could have an approximately 1-5 day process time