CHANGE OF CONT Application# t_4 c)--7 o
Harnett County Central Permitting
PO Box 65 Lillington,NC 27546 - Ph:910-893-7525 - Fx:910-893-2793 - www.harnett.org/permits
Certification of Work Performed By Owner/Contractor
(In du Trade‘469lication)
Owner(s) of Structure' Phone: 9/7
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Owner(s) Mailing ress: ZSSD ., U r S eiS-
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Land Owner Name(s): NA e4IJ 7</&tAbot 1NG, Phone: 9/ �37 6A.
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Construction or Site Addre G /l �rrd2/Orf y�/#���111"'
PIN# OSOS— &9. 9V3/. 000 Parcel# 0/O53S2S b/OC 3-7
Job Cost(Required): Description of Work to be done Ner✓ 6/50-4C/401
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 Llllinoton:
Subdivision: hilthietkla L/ceS did /41rr1y _ Lot it: I/O
I &Are elea-7r7t will provide the GYM//r2Ga/ labor on this structure.
(Contractors Name) (Trade)
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.
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Contractor's Co�u�gany Name Telephone
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Address / Email Address
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License it
Structure Owner/Contractor signature. ,�,<Gh GG GCG'1' Date: 9-24-/9
By signing this application you affirm au have obtained permission from the above listed license holder to.
purchase permits on their behalf. If d- • 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