DOCUMENTS Application# 145"'-)q 3 VS
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 0 ner Information(To be completed by owner of the ma✓✓nufactur ho Te) O
Name: OA&X,1 1�au.�uw Address: 3( C 04C a-CL
p 3 o AI� coity: t LiP Stale: Zip:,27CY�.. Daytime Phon t l' p1(J-O(�g-�'
Landowner Int motion (To be completed by landowner, if different than above) 1
Name: Address:
City: State: Zip: Daytime Phone:( )
Part II-Contractor Information(To be completed by Contractors or Homeowner,if applicable.
Name,addres3 8 phone myst match information" oron license)
A. Set-Up Contractor Company Name:FJy5u1,� S�'t' PIPO
Phone: 11.1-120"M'S Address: i•o 6,IKV 54-*
City: )\nt.f\ State: A•C• Zip: aft 1.1q
State Lic#L0 ,52. Email: // !! ,�
B. Electrical Contractor Company Name:
.•''''. &G e/eef1e O4- SA-t- A
Phone:f/Z(-(t #_ L¢g. Address: <t' ', Iaay LA
City:.JI��`Any6✓ State: f C •- 1 Zip: 2"17,1-51
State Lic# /5 :11. I L. Email: t• 9h e,-2 Q lJ.Yri. Sherri-an • /✓ef
C. MechanicalContractor Company Name:=\oat. CtMestrE4.IL f�r
ic
Phone: 1 I /(-6S0-�`g7 Address: S�1 i Aft am Aov4ir
City: _`' coda" Slate:Ar•e- : zip: 1ZS3 f
State Lic# aacas Email:
D. Plumbing Contractor Company Name: FtLOA7q W,14br7
Phone:p�4, 19`'-� 1244061.. Address: Po (WA 5:13
City: '' f c4 State: OJ- t . zip: x150'2
State Lic# ( (S Email:
Part III-Manufactured� Home Information
Model Year: 1170ctSize:a X 40 Complete& follow zoning criteria sheet
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 have obtained their permission to purchase these permits on their behalf, and that the construction or
installation will conform to the applicable manufactured home set-up requirements, and the Harnett County Zoning
fice. I understand that if any item is incorrect or false information has been provided that this permit could be
d. Vida'ry11. 1A,IV dMQ).vu-1 &/�
Signature of Homri*Qwner or Agent e
'Effective July 1,2004,a Couuy 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 fhe
Form 500 and if available,the serial number.
List of inspections and Egress requirements available upon request. Progress Energy customers must provide Premise Number.
SETUP 04/11