TRADE Application # // � Z Z
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 Sf nSe1 diai ' Phone kg
Owner (s) Mailing Address / /6i, 5fai(»
Land Owner Name (s) Phone
Construction or Site Address 1) 6 4' kg, L,4 ddn) 1- 4nl
PIN or Parcel # from GIS L ! 0 / 0)
Job Cost Description of Work to be done / 7,0 Ty
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
Specific Directions to Job from Llllinoton Kr`� /
e ./ G ..
Subdivision ' ./. I I Lot # / r
I 44 V Y r will provide the ifif�t labor on this structure
(Contractors Name) (Trade) ��,'
I am the building owner or my NC state license number is < U`v.0t 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 LS 1 kle,-dp Z1�c d- _ Date 777aaOd /4
Company Name Phone
Ad. ress County
Contractor s License # - : •dress
Contractor's Signature II ate
•any name address & phone must match Information on license
Individual Trade Application 1 of 1 06110