TRADE From: 02114/2011 10:15 #071 P.0011001
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t/°' �' G (r A , orb ( � APPllcation # f 1 5 9 Z /_ &Cl
9 I G '" Harnett County Central Permitting UUU
11 am , ) PO Box 65 Lillington, NC 27546
l 1111 910 -893 -7525 Fax 910- 893 -2793
c www.hamett.org /permits
Certification of Work Performed By Owner /Contractor
(Individual Trade Application)
Owner (s) of Structure: 'Ji.f vi ; u s t✓bou✓ / Phone:
Owner (s) Mailing Address: WO" &Z4y A epo#1rt 41 15:1:11 4/21-, /Ye,
Land Owner Name (s): :174, hr Ref cia914 Phone:
Construction or Site Address: ¥ f a. / <y 7A s,� // _ /'
PIN or Parcel # from GIS: �/ 7 /D /I ;o /J 7 ! I /1/ — 5 / 3 — 27Ai I. , is
Job Cost: ..-Z6i24 9Description of Work to be done ... , : r
A m 4 zfr
Mechanical: New Unit With Ductwork _ New Unit Without Ductwork Z 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
eci c irecti. s o Jo. o Liltin•to : _
9 , 19
4 ._i._.i � y � ' .r te �r � !+ „ ! G 4 'N
ll Subdivision: Lot #:
I Aneric wariesic t stn a /SBry will provide the _ Mae labor on this structure.
(Contractors Name) (Trade)
I am the building owner or my NC state license number is to/KJ/4125W which entitles me to
perform such work on the above structure legally. All work shall comply with the State Building Code
and all other applicable State and local laws, ordinances and regulations.
Structure owner(s) signature: // ,74 Date: "
/RS.iii s
Company Name: An e ;ranJf�fir.n / /. rvii- Phone: 11 ersZr.5/97
Address: 5/7 i/'Iran 4- A'.a /c yhA 274E County: 1144e
Contractor's License #: //r. i MX/ Email Address: /9 .4..a. / %sa
Contractor's Signature: Ze ,..- 4. /s. r -..., Date: dt� �� /7I
'Company name, address, & phone must match information on license.
Individual Trade Application 1 of 1 06/10