TRADES
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Application #
Mall
Please note if this application In agpiication
Harnett County Central Permitting
is part a Jr J-~
of a job i progress
with open permits. PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
-yes _ no www.hamett.org S r S
Certification of Work Performed T
By Owner/Contractor
Contractor Information
I, Ag*~ ,i LCv . will complete the V4L work on the project or
(Name) 18 S (Trade)
structure herein described. My state license number is CI+ss I . All work shall comply with the
State Building Code and all other applicable State & Local law, ordinances and regulations.
Company Name: 02M
Mailing Address: ssJ_ i?o s sett s f- .
Street Address: v) - ( . ?0
Business Phone: (,q t of `I 3 { - a-~ ) Email Address: dgYa"J ,,igkt hvac . o „
'Company name, address, & phone must match information on license.
n Job Information
Land Owner's Name: VCO~2 rT Yeller Phone: ('A gI )2 S -o - 1)Q O ,
Tenant/Building Owner(if different): Phone:
Construction or Site Address: g~ 1 C o o c.\ M Gn ~ J ra N c d 133,,
PIN or Parcel # from GIS:
S ecific Directions to Job from Lillin ton:
n B, rc lb "Ize-s PC) Tn (0",Y,1 "„w L~~fs
eD, ) CIecJ- ,cv ( se/ v; Le is eI.C L+ r" L. I~
Description of work to be done: Q4onSHP w,+t,~ OwtworK Job Cost:
Mechanical: New Unit With Ductwork New Unit Without Ductwork _ Gas Piping _
Electrical: 200 Amp _ <200 Amp _ Service Change - Service Reconnect _ Other
Plumbing: Water/Sewer Tap _ Number of Baths _ Water Heater
Permit Cost
Permit Fee: $ O (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application / Gee- YtW``
Total Enclosed: $ S'3 • 00 L cv,.t )'f- I
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546
Contractor's Signature: Date: ~a 3a D
D01VOTSENDCA"Ll S INCOMPLETE A PLlCATIONS WILL NOT BE P O ESSED.
0/06
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