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SET UP Application # Cq q f ' 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 I — Owner Information: Home Owner Informaation TTo bb completed by owner of the manufactured home) /, / /� NameOl {! A A d- . Ql /.!P Address: R7 ( _ L Uif%(l�li7_5 , .• City: & /) /1.(r/ eip { State: y]. O. Zip: da2,3Daytime Phone: (9 0 Si'! -67a, Landowner Information (To be completed by landowner, if different than above) Name: Address: City: State: Zip: Daytime Phone: ( ) Part II — Contractor Information (To be completed by Contractors or Homeowner, if applicable. Name, address,4pphone rpu t mattc iformationyn license) A. Set - Contractor Company Name: Lhla) ( - TJhMFS - / -1✓(°, �l v 5 - 4 0 o 9 1; t'3G v(L . Phone: /r7 � x,579 Ad dress: City: it if .._ � State: • - ' Zip s �-3 mail: Setu• Signature: I ff. LA it_ State Lic# (vCg40. • B. Electrical Contractor Company Name: -14.6on f1 7b nclnka ( 4-rcdcrr Phone: 9/9 714.0 - 0Y37 Address: JSo3.x(fr 169- A%,)r- nri e- City: 50.41k State: /VC Zip: 0 Email: k dec# 'cl(crAcfr 1,jcorh Electrician's Signature: V tate Lic # ,2'7- f1 `/'U / - C. Mechanical Contractor Co any Name: it r lfr.. 1 , • ` J Phone: it g l q - 0 7 /96 Address: ( 7.:. T L 4 f/ //rags 24,t C.__ City: le ■ �,: / Stat-: /. d Zip:. Email: HVAC Signatur-: ATM M i n , St Lic# A)HP d///lle/2 D. Plumbing Contra tor Company Name: s, i DSO 4 J , , {2L Phone: t 10 �/ I 2 706 Address: 7 l 7'� J et_ �.f /tl�g,a,t /AA e____ City: M. J/ /L O (, $tal4A .�. t30Z3 Email: e m Plumber's Signature: 9 I f�t+ P / e___ State Lic# 7 Part III - Manufactured Home Information Model year•! % /l 9 D Size: D X 740 Complete & follow zoning Criteria sheet A - t 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 inform. ion as been provided tha is .: mit could be revoked. / Al at4' - /. -1 -„E " /-O4' 7 -a ignatu - of Home Owner or Agent Date ‘ i *Effective July 1, 2004, a County Tax Department Movinc 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. Progress Energy customers must provide Premise Number. Mobile Horne Setup Application 1 of 1 12/10 Gt MVR -2 (Rev 11/96)? North. Carolina of Motor Vehlcfes j N' DEA REASSIGNMENT OF-TITLE TQ A MOTOR VEHICLE 'To be used. by NoRh Carolina • IiCensed dealers:to reass out -of state assignetl certificates of btle;• -titl stale reg c e rl lficates and]otr bills of sale ` or other ` doquments.acceptable for obtatrung a ceruffdate of lige in North Carolina for vehicles. acquired by North Carolina dealers May .p ign manufac s degiticates ofprigir i and North Carotale certi of titl wean me space or spaces provideed on Ihes do for dealer sassig iil use s to been reass Used , . f, / ` ; VEAR 'iC191J MAf<7 ( BODYSTYLE�n?�JC4� :VIN I��/ e"IQB3X8�1`A�i' Federal a law requires that you,state the m ileag e m connection Wlth the transfer of ownership Failure to complete or providing a false state merit may result „in fines and/or impnsonmeot , REASSIGNMENT OF TITL BY LICENSED DEALER; The Undersigned Hereby emhes hai tFjgvehicte es y stile lisle has been transferred to the, lowing printed�naor and address: ,e�,G�/ • u5, �. t i -,.. , 11S t754W#ka � certify to the ne of the f bast of m knowledge that the R o meg Is (ND TEI THS) and reflects the actual mileage of this vehicle unless oll nts. is checked: t . . 1 Thy m i � owing stateme state t &in Excess of us mechanical limite. z i' 2. The odometer read is hot the actual mileage . ,WARNING — ODOMETER DISCREPANCY • V , 1 ATE VEHILE E VERED TO PURCHASER . To MS howl the v ebiole descri Has been involved In a bed here D DLI yes y No y W IIision Mother cu t: the ex the cost 10, repai x e ceeds . 25% of fair martial retail value t ,'-` Ves ❑; NO ® Has Deep a flgod veNde a / r aee / !)s itu d oc veh rre le of a sob ent 1 at Signature o Name and ' / • ; G , Signature of 0ealer or A ¢tt � lf i% i 4 P l i P.}inletl Firm Name � r �l� � ! ti �r� �� Acknowledged before me this day o1 County State Notary Public My Commission expires the day of 1 am aware DI the above odome ter ien abon and dam* disclosure made by the settee EA ,,, ,w� ; 1 Hand Printed Name and - ' -( . ) , far' .. `! f - . I Slgnature(er of Buyer) �► ' // -// 4 ✓11 /r wt . /iii Sj ;® N® OWYI.h �allYI.HI = CY /.�.1'_tl' // � RE AS IGNMENT OF TIT E BY LICENSED DEALER; Tinted na The Lntlersignetl hereby cedifi th the vehicle descnbetl in Ihis lisle has, been transferred to the IolloWmg p ,.me and address . ' , • ' °I certify to the best of my knowledge t hat tli'@ CdDmeter reading Is (NO TENTHS) and re'flecls the acftial mileage di this vehicle unless' .. k One of the following statem i `© 1. The mileage; stated IS In'exoess Witt Mechanical Iirhits. ❑ 2. The odometer reading is not the actual rnileage WARNING — ODOMETER DISCREPANCY Tom llnowl @dge the vehicle described herein:, ' . .. PATE VEHICLE r)&IIVERED TD PJgCNASEI • Yes NO Has been'fnva ed in a c01151pn or other occ urrence toljle extent that the cost to repair e 25 < o WU markbi retail vaillfl 1 • YES ❑ Nd Has bean a flood vehicle; a reconsirudatl vehicle or a salvage veNCYe , ` 1 Hand Pnntetl Name and a Signature Of Dealer. or Agenf ' Printed FAm Name, �- DealCrNo ,� nowledged before me this day of County e < State I Notary Public - ' - n Commi ss ion xpee eu the day o s Ack 1 aei aware of fhe above odometer ce t i fic ation and dafnage disclosuie madeby the seller, (SEAL) Han 'aware ed Name and .� * , : r 'R ASSI GNMENT.OF TITLE BY-LICENS O DEALER , The undersigned hereby cenif+@s -.that the vehicle descnbetl I rs this title has be transferred to the,toIfowmg pnntedlname and ddtlress c > , 7 codify to'the best of my knowledge that the pdcmeter reading is `(Nil TENTHS) and Fflecs the actual mileage of this vehicle unless one of the following Is checked:.. ' ❑ - 1 . The mileage stated rs•Imexcess 01 Its me bmils l] 2..The odometer reading is not Iheao ntdeage WARN ING �gDOMETER DISCREPANCY.; '� ' To my knowledge the vehicle described herein: ' 'DATE VEHICLE DELIVERED TD PURCHASER yes ❑ ND ❑ Has been,Invofved in a colkaion or other occurrence to the extent that sty cost 10 repair excee 259 of fart market retail value [ Yes ❑ No p Has been'a Hood vehicle, a reconslruded vehicle or a sewage veh'Cle.. .Hand Printed Name and • @ @@ 4 Signature of Dealer,or Agent Printed Firm Name: Dealer NO h 1 ' Acknowledged before me this -,day of County - �Stal@, ,r N&&y Pubic "', My Commission expires the day ot 7 ern ware of the above odometer cerbfical,on and damage disclosure madeby the seller. (SEAL} - I 1 Hand Printed - Name k Signature( s)oreuyer(s) - - - LIEN OR - ENTER Jo. OWNERS APPLICATION, FOR TITLE ` T hf a l eontarns the conrorrriln odometer statement and must have the h and printed name and S ignature o ba the bu ye r end seller