CHANGE OF CONT Application# I /S7J4a10 0
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
(Individual Trade Application)
Owner(s)of Structure: Phone:
Owner(s)Mailing Address:
Land Owner Name(s): Phone:
Construction or Site Address:
PIN# Parcel#
Job Cost: Description of Work to be done
Mechanical: New Unit With Ductwork_ 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: O��I1////���///
Subdivision: Lot#:
I will provide the 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.
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C rc2t s Company Name �� J Telephone
Ce Address 83v5 Email Address
ria.o 6,
License#
Structure Owner/Contractor Signature: A. . - - _ _ ' Date: IVO LI - 7- .,1v/7
By signing this application you affirm that you have o' - nedper on fro'the above listed license holder to
purchase permits on their behalf. If doing the work a.•r ner yo dersl-,•• that you cannot rent,lease or sell
the listed property for 12 months after completion of the listed k.
*Company name, address, & phone must match information on license