TRADE
Application #
Please note if this application Mail In application q X
is part ofajob in progress Harnett County Central Permitting
with open permits. PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 Fax 910-893-2793
_yes no www.harnett.org
Certification of Work Performed
By Owner/Contractor
/I Contractor Information
I, -Z. g~ QA, will complete the 9 V)q-C work on the project or
(Name) (Trade)
structure herein described. My state license number is tF I L . All work shall comply with the
--State Building Code.and.atll other applicable State & Local law, ordinances and regulations.._ _
Company Name:
Mailing Address: S 4 L 7 fo
Street Address: -a-
Business Phone: S I S I Email Address:
'Company name, address, & phone must match information on license.
b Information
Land Owner's Name: i Q-xt o_ Phone: 9 /~9G 3 d
Tenant/Building Owner(if different : Phone:
Construction or Site Address:
PIN or Parcel # from GIS:
S ecific Directions to Job from Lillin ton:
- r~--
r, JQ" r~- ! 7~
~od
Description of work to be done: l 1~ 3 I ll Job Cost. 3~ 0 d- - -
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: $ So 0 (calculated from fee schedule)
Mail In Processing Fee: $3.00 per application
Total Enclosed: $ S -3- 6 0
Make check payable & Mail completed application form to: Harnett County Central Permitting (HCCP)
PO Box 65
Lillington, NC 27546 \
Contractor's Signature: Date: 3- 3-r 0 ( JJJ
DO NOT SEND CASH. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
10/06
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- " Ov✓ner Inform~6on r ' NAME POPETOMMY
r?. ADDR1 1510 SILAS MOORE RD `
j ADDR2
ADDR3
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AA CITY + COATS
1n STATE _00, NC ri
ZIP 275210000
` Parcel InfOrG~110❑ - i1
` PIN O~ 1601-95-4087.000 !P
PARCEL ID 071611 0100 ' i
REID O~ X0017268
SITUS ADDF S SILAS MOORE RD X
LEGAL _1 36.04 ACRES
_ ~STEPHENSON
LEGAL 21557 NC SR
LAND_UNIT5- 1 ,36.04AC
TYPE
CALC ACRES (34.69
OOK 01469
X0546
s. _ ED PAGE
5mi
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ite Information
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d T PIN LEGALt
1I071611I1601_95-36.04 ACRES 11557 NC SILAS MOORE 136.04 01469 0546 0 47510
0100 '4087_000STEPHENSON_SR RDX
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http://gistools.harnett.org/Freeance/Client/PublieAccess l /index.html?appconfig=public 1 3/8/2010