100 N King St
Hendersonville, NC 28792
CANCEL PERMIT REQUEST
Phone: 828-697-4830________
I, _____________________________, hereby request the cancellation of Permit #_____________________
For the job located at ______________________________________________________________________.
Has any work been performed in reference to this permit: Yes No
Last Activity Date: _____/_____/________
Reason for Cancellation: ____________________________________________________________________
I certify that I am the license holder or authorized agent for this permit.
I also understand that a new permit is required to complete the work described on permit and that none of
the fees already paid are transferrable to any new permits issued.
_____________________________________ ______________________________________
Applicant/Permit Holder Signature
_____________________________________ ______________________________________
Contact Phone Number Date
_____________________________________
License Number (if applicable)
NOTE: A SEPARATE APPLICATION MUST BE COMPLETED FOR EACH PERMIT BEING CANCELLED.
Processed By: ____________________________________________________________________ Date: _____________
