SET UP Q5 - 77g
Application #
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:
Horne Owner Information (To be completed by owner of the manufactured home)
Name: 1 L .1, % If Address: 921 i& tf ;443 Jeff
City: . . i , r tate: 1 Zip o77 CDaytime Phone: ( ,390 -W.5 S
Landowner Information (To be completed by landowner, if different than above)
Name: PAn) fi7-/f7 3r Address: / 9/ Ke' 4/, e��-s' ,Faccf
City: 11 77w „ State: NO Zip: a7i f' Daytime Phone: (cifql R '43 4 —C 1 ( S
Part II - Contractor Information (To be completed by Contractors or Homeowner, if applicable.
__ Name. address, & phone must match information on license)
A. Set C Contractor Company Name: C 1 {/7 Q V\ 't ( - IA r -re '
Phone: 'WO q56 ti - 7� Address: 0 655 3 5 5'7,5- ,
City: - E_ / / tate: - Zip: 21? 320`3
ISei T Wail--, ': ” State Lic# X 32
B. Electrical Contractor Company Name: ♦,- vrE- C r vy.r-7
Phone: o f — 6 -96 Address: Q 2 ( h, i V; via 2c)
City: •_ ♦ ./State: C- Zip: �1t29
Electrician's Signat e. . 4. / ' State Lic#
C. Mechanical Contractor Company a me: /G- viP r1 ∎ i1 rKi) i -
Phone: 9Ict - 7R9'(I -'6 35 Address: cpc ((,i-..S Red
City: F3 C .({r State: 1-( C a
. . Zip: 1n =
HVAC Signature: (.), //_ State Lic#
D. Plumbing Contractor Corn p any Name: - bnine r> , , inP.,-
Phone: gi - 3:10 - 3 Address: q at g
City: C- 11 . o• - V-- rat,_ State' l' C - Zip: 7
Plumber's Signature. , State Lic#
I
• Part III Manufactured Home Informat • n
Model Year: 2003 Size: (4 X 9 # of Bedrooms 3
Park Name: la- t / toy 'L ; 1( ..e Lot Number: Li
1 hereby certify that I have the authority to apply for this permit, that the application is correct including the contractor
information and signatures, and that the construction or installation will conform to the applicable manufactured home
set -up q irements, and the Harnett County Zoning Ordinance. I understand that if any item is incorrect or false
infor at has be- - .. ided that this permit could be revoked.
S ar /2- 6 - .20/0
g : ure of Home Owner or Agent Date
`Effective July 1, 2004, a County 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 the
Form 500 and if available, the serial number.
List of inspections and Egress requirements available upon request.
2/08
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