TRADE - ELECTRICAL
Application # 4 ~G ~o~D~lo
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Certification of Work Performed By Owner/Contractor
(Individual Trade Application)
Owner (s) of Structure: r Q A11 WXf ,nNS M'Nisj Phone: (glcl4gr1''1lOb
Owner (s) Mailing Address: (o'l l w . N1tWl !r1¢SR Qcz c~•
S ' Lra t, C. Z ~ l7
Land Owner Name (s): Te r1. F11~ A)AA:e S Phone: (g10 ~4g'1- rlno
Construction or Site Address: _4 .4%waA Zu, to. SDt `bi4 LAVI_ u
PIN or Parcel #from GIS: J ,
Job Cost: u 00 Description of Work to be done Ra ; r i hSbQ ,
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork _ Gas Piping
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
cific Direction o Job from Lillinaton:
S. -Cr~.ReS Sir N< LiL1ca Oe~ R LY.
ONE[: %)Wleg
T - f Q
Subdivision: 1 tit JAS Lot N A.
i Tv~rlt' will provide the F~~c fir: r r. t labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is AMUO_( which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code
-and all other applica6le State and local law s, ordinances and regulations.
Structure owner(s) signature: Dater
Company Name: ="4L Q.C-~ Phone: Vt10 t }Kl' oe 4 0
Address: LAo1 ! A~ N
County: Contractor's License #:X1366 -0
Contractor's Signature: .r~ Ay- Date: 17-C-116
*Company name, address, & phone must match information on license.
TRADE ;r+ Ra~er~~ 4/08
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