BUILDING Application #
X17 26
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 1 A cloy on Phone
Owner (s) Mailing Address
Land Owner Name (s) Phone
Construction or Site Address 9 21 La it r. d t vC C.,,, c -v n/ c tPJ Z 6
PIN or Parcel # from GIS
Job Cost Description of Work to be done
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 Llllington
Subdivision Lot / / #�/A / / ///
I /4 0 )�/' /ice' will provide the �/�fij.f' /l, labor on this structure
(Contractors Name) (Trade)
I am the building owner or my NC state license number is A 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 ncces and regulations
Structure owner(s) signature rl-�J � lA Date 3/
C. rr any Name Phone
Address
Contractor s License # -01 ,1 Address
Contractor's Signature Date
Company name address & phone must match information on license
Individual Trade Application 1 of 1 06 /10